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f. � APPLICATION FOR SANITATION PERMIT Permit No. .__.1D. ._ ` UI • (Complete in Duplicate) /oI r Date Issued Application-is.hereby made to the San Joaquin.Local Health District for a permit to construct and install the wor herein described. This application is made in com liance with County Ordinance No. 549. j - JOB ADDRESS AND LOCATION_ Owner's Name r_------- - # _-- - one _-- ...x. 1� Ph Address ------------------------ �. � z Contractor's Name + `'°' --'^ -----------------------------------•-------------- Phone- -•------ -------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other p Number of living units: _L____ Number of bedrooms 3--- Number of baths _A_- Lot size -___ _. ___-------__________________________._.___ Water Supply: Public system ❑ Community system ❑ Private [Depth to Water-Table'_"ft. ..... Character of-soil to a depth of 3 feet:�.Sand Gravel ❑ Sandy Loamay'Loam ❑ Clay [] Adobe ❑ Hardpan ❑ -•Previous Application Made: Yes ❑ No New Construction: Yes Ej iso ❑ FHA/VA:,Yes Z' No ❑ TYPE.OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) r� „`^r yw'f e, -L 4 Septic Tank. Distance "from nearest well_7(1__. Distance from foundation__/_ Mate ria#' =? �+-� .� _------------------- No. .__:_ _ __-.-�• No. of compartmerifs--------2..—__'_--r- �Size___�__2� X_�._X..._Liquid clepth-------- ------------Capacity...�_�-�,�'.- `Q Disposal Field: Distance from nearest well-7d__2_.Distance from fou ndatio�n_f _ __Distance to nearest lot line_a�___---";"'171' ® Number of lines_____ __ ___________ ��ength of each line_ !_ (_ __.Width of trench._.:�.__��-___._______._-__ Type of filter maferial__ r ._ Depth of filter material_.--��_ ..-_�r _______Total length_._-._ tj7j'x'.1_'_41___________________ u F. 4 Seepage Pit: Distance to nearest well--------------- ___--_-L'__Distance from foundation----_______________.Distance to nearest lot line___..__.___-__.-.El fr` Number of pits---------- --------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- O+ Cesspool: Distance from nearest well.................Distance from foundation___.__ _ .._-____..Lining material____ .___ .____..__.___.________-_--. - F ❑ Size: Diameter---------------- -n----------------Depth----------------- ---------------------------- ---Liquid Capacity---------------------------.gals.-0 - F a. Privy: Distance from nearest well_'______`_."___________________________________Distance from nearest building ❑ Distance to nearest lot line--=------ ----- ------------------------------------------------------------------------------------------------------------------------ Remodeling -------------Remodeling and/or repairing (describe):--.-.--.--------------------------------------------------------:------------------------------------------ --------------•-----------•----------------------- --------------------------------------=-------------- --------=---------------------------------------------------•-------------•------------------------------- --------- 1 ------•----------------------------------------•------------•------------------••----•---•----'•----------------•------------------------------------------------------------------------------------------------------------ I hereby certify the I have prepared this application and that the work will be done in accordance with San Joaquin County Jr ordinances, State awyand rules and regulations of the San Joaquin Local Health District. (Signed)----------- -------; c -------: ----- --- ------------------------------------- d•f er Contractor), (Awxrer�err (Title)_ s [ g wells,, b�uilldings,,etc., can be placed'on reverse sidel. Plot lan,,s showing size of lot, of system:m relation to �- -�--- .. _.. - F,OR�I3EPA�tT Zt- . r MENT USE O LY _ APPLICATION ACCEPTED BY.----- --- -- F-:-�' �- . �- --=-�--=----•---=--------• DATE_._f�e� �--- _� --------------- REVIEWEDBY ----------------- ------------ ---------------------------------------------------------------.--..DATE BUILDING PERMIT ISSUED-----------------------=---------------- ---------------------•--------------------------------------- DATE Alterations and/or recommendations:__ 1 r+ _-. f}(-�"'i„1� ��^ :._ ---------=---------------- ------ ----- --•--------------- = - ------ -- ------------------------------------------------------------------------ - - r FINAL INSPECTION BY:---=- -- - A-_'.--------1-=-- ----- bate-- --- - -- ------ ------------------------------------�------------------- SAN JOAQUIN 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 ES-9-2M , Revised 1.57 FRCO. A