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/ v APPLICATION FOR SANITATION PERMIT Permit No. .11� * (Complete in'Duplicate) _ Date Issued .._ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work here'sn described. This application is made in compliance with County Ordinance No. 49. JOB ADDRESS AND LOCATION............. >Q �___--- - --x-_- -------------- Owner's Name ------------ -- --- '- -------1- ---- 1;51. hra� - Phone Address---- -�- is --- Contractor's Name =v Phone - . Installation will serve: Residence E4--Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Nu ber of bedrooms ---?--Number Number of baths .� Lot size .-_.-.. �/ ----SAO C'_1 t Wafer Supply: Public system Community system ❑ Private ❑ Depth to Water Table3... ft: Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe�rdpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No E!� ANA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) i Septic Tank: istance from nearest-well------------------Distance from foundation.............k.__- Material .._-._..._-- of compartments ; Size Liquid depth --------Capacity---------t-�Q--•-- DispTos�al F- Distance from nearest weil_'�=.4 ~±-a"Distance from foundation.-7ZO...(------Distance to nearest lot lip l L P Number of lines..._ -- � -------------------------Length of each line-.---t��..... _.....____-.--Wsdth of trench__--�,�.._�- Type of fiiter m+teriai._^t-�_G-k--Depth of filter material--..�. _��-------Total length-._.�-, '7-----__-------------• 0 ..._. . Seepage Distance to nearest well-----V-=- -Distance from foundation--1...............Distance to nearest lot __---- - �j"C1 ® Number of its-.------- -_- GG /j C?� Number i p -----.---Lining material -- .Size: Diameter_---- ., -------.Depth_... , _ ------_-- N Cesspool: Distance from nearest well-----------------Distance from foundation_.....-____------- Lining material---.-._ .-- _`r�-__-_- . ❑ Size: Diameter.-1----------------------------------De Depth Liquid Capacity- --------gals Privy: Distance from nearest well-______________-.-.: __.__' ------------------ from nearest building g — --.gyp. ❑ Distance to nearest lot line----------------- - Remodeling and/or repairing (describe)--------------r2_ kA----7�zIti---___ at ------------------------------------- i ------------------------------•---------------------------------------------------•--•-- -i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)---------------------- L '� er and/or Contractor) By--------------------------------- e (Title- -------------- - (Plot plan, showing size of I cation of system in relafion to wells, bui mgs, a+c., can be placed on reverse side). ' 1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- ---------------- -- ------ DATE_..-...-- -. ------_-_--- - ------------------ --------------- 111 REVIEWED BY - ------- ---- - ----- DATE--------- BUiLDING PERMIT ISSUED - r------------e'---- ---- ---- ---`--- --------------- ---- DATE------------- Alterations and/or ommendafion --_-,- --------------------------------------- _ l --- -------- ------------------------ . _ - •- ----- ---------- 1�-----�� --------- �� --- --- - -------------------------------------= - -------------------------------- - -------- ------------------------------------------------------------ `- FINAL INSPECTION. BY:.------ =--- ----- Date-------- 6 }} SAN7JAQQUIN LOCAL HEALTH DISTRICT f30 South American Street k 300 Wer+ Oak S+ree+ 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M • Revised 1-57 F.P.CO.