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Permit No. APPLICATION FOR SANITATION PERMIT (Complete in .Duplicate) "V/vDate Issued _ ?- Application is hereby made,to the San-Joaquin Local Health District for a permit to construct and install the work herein described. This applicefiori is made in compliance with County Ordinance No. 49. JOB ADDRESS AND L CATION E Owner's Name ' ----------------------------------- _al II - ------------------------------------------------------------------•-------- - ----- - ----------- ; f Contractor's Name 'I --- - *'` '-----------------I------------------------------------------------- Phone °_ v_S Installation will serve: Residence Apartment House ElCommercial ❑ Trailer Court E] Motel E] Other..❑ f f i Number of living units: _/__ Number of-bedroo-ms3-___ Number of baths /----- Lot size _ ___h ___ --r_-.__.________ Water Supply: Public system ❑b Com munity'systerri['0 Private N' Depth to Water Table 3 ft. 1 Character of soil to a 'depth' of 3 feet. Sa d`, Gravel ❑ Sandy Loam ElClay Loam ❑ Clay ❑ Adobe ❑ Hardpan C]I Previous Application Madel yes ❑ No �- New Construction: Yes ❑ No �1=HA/VA: Yes ❑ No El TYPE OF INSTALLATION VI i ION AND SPECIFICATIONS: , i (No septic tanklor cesspool pirinitted`if public sewer is available within 200 feet.) e hic nk: ' Distance from nearest well_________________Distance from foundation---- ---------------Material--------v____..____-_.___-__--_________--.-____. No! Mcompartments------ -------------------Size...------------ ----------------Liquid depth-------------------------l Capacity----------------------- Disposa Field: Distance from nearest'wellI-'7/_,Q-_.._.Distance from foundation___. __1A!.____.Distance to nearest lot line___ ________- Numberkf-lines__ `___ k'-!__ Length of each line..._ Width of french.------ 5/ Iype.otJilterrmeterialJC._. / ._�_ 'e.f3e fh of filter material------ len thA-_. 4 ` _.Distance..to nearest lot line.-_----_-_-_ Seepage Pit: Distance to nearest.well__-_- _`__i�f_SDistanc on", undation-_-��_...._ } Number"of pits--_ __-______eLining mateal_ {�F Size: Diameter___.s _________.Depth__._.tT�_�............... Cesspool: Distan"c" -from-Flea,res#�wsl1.:�,� _ ----Distance.from,foundation___._,._..............Lining.material_______-_____.-________________-_. � ❑ Size: Diameter------ ----------- ---T--`'---------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well ------------------------------------Distance from nearest building_____.____________-_____-____._____... ❑ Distance to nearest lot'line----------==---= ""'" 1 ------------------- ------------=--------- --------------------------------------------------------------------- Remodeling and/or repairinlg (describe}------------------------------------------- 0 --------------------------------------------------------------- ------------- -------------------------- --------------- li, -- . --------------•--------------•----------------=----•---------------=-----------------------------------_-••--------•---•---------------------------------------------------------------------------------------------------- - 1i I hereby y that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, t to ws, an�ru' sand egulations of the San Joaquin Local Health District. [Signed} --- iI ------ - caner and/or Contractor) C. -------------------------- ------ --- Title ---------------------------------- ----------------- B ' ! ( } [ p y g ot, location of system in relation to wells, uildings, etc., can be placed on reverse side]. ' Plot Ian, showing size of I s � FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----<-------------------------- DATE--------------------=-f- REVIEWED BY-------------------------------------------- r' y ' ------------------ DATE------ ' BUILDING PERMIT ISSUED-----------------------A---- �__ - E DATE ` - Alterations and/or recommendations: -' -- --------------------- ------------------------------------- •--- -•--- ------------------------------------------ ------------------------------------------------------------------------- --------- a :- -- ----- --------- �� --------- -4__ M------ . --------------- ---- =�-------------------------------------------•------------------------------------------------ ----------------------------------------------• --------------------- ----------------------------- ------------..----------- ------------------------------------------ ---------------------------------------------- -------------------------------------------=-------------------------------------- - ----------------------------------------- ----------------------------- --------------------------------------------------------------- JJ FINAL INSPECTION BY:``_-- -_ __ - -- _ _ Date__/.l'//q-�-------------------------------------------- pl SAN JO QUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California q ES--9-2M Revised 1-57,F.P.CO.