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APT!ICATION FOR SANITATION PERMri-f' Permit No. ._Gf�J. (Complete in Duplicate) ��{ Date Issued ..... .._: !S1. Iea Applicati n is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance/ with County Ordinance No. 549. JOB-ADDRESS_ D LO ATION....! ..7---.._ t!_. ----r-- ---------- -- ................................. ----..... ---------- ..................... --- - e. Owner's Name.---------- .. . ... ........... -- -- - --........ --------------------------------------------------- Phone...............------------------ Address------------ � /l ------ - --------- - -r - - - Contractors Name - - - :£ - --------`----" --- _...-- -. - ---. --------------------------------- ----•-- Phone :. - - - -- ------------------ Installation will serve: Residence Apartment House ❑' t Commercial E] Trailer Court ❑ Motel ❑ Othpr ❑ Number of living units: _--'..- umber of bedrooms -.7__ Number of baths .1----- Lot size ___ .I__x_�7�!�C-_-_._.-.__________________ r Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam [I Clay E] Adobe Hardpan ❑ r. Previous Application Made: Yes E] No 5a/ New Construction: Yes [ No ❑ FHA/VA: Yes ❑ No " TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permiHed •f ublie s er is available within 200 fe//e��t��) j '/y e� Se tic ank: Distance from nearesfi wel Distan frf.�^/fo tion�bl._�CS':_.Ma ial_- - _ P .;ofcompartments----_--�7i/A,-,-_,-------]Size_f/'.x!1t-_X ._Liquiyd�r�depth-�_ r_--______.. apauty-____�.L7.. i Dispos Field: Dnce from nearest welt/"C_-'tT:SrS.Distance fromfoundation�.(l.Xl'Y"r.'zDistance to nearest lot 'n _'s p t :n ._... Number of lines_...._.__ _ Length of each line----__--_---'Y ,,_-Width of-trench____--____-__---_ Type of filter materi epth of filter m -- Total length-_._...-_.._.....�. V.---_ Seeps a Pit: Distance to nearest well.-. --&4 Distant rom f ndetion�Q °�DistancVo nearest lot -ne_ �r q - - .. Number of pits--------1�i-...--Lining material.(I��'tt.__�__t�-'Size: Diameter..----�-s�a-------Depth-------- - -- ------------ Cesspool: Distance from nearest well________________Distance from foundation___-_-___...__-.Lining material._._.....__._._____._-___-..... <. ❑ - Size: Diameter------------------------------------- Dept h-------------------------------------------------Liquid Capacity----------------_....-----gals. Privy: Distance from nearest well...... .---------------------------.------------Distance from nearest building----------.-------._................ ....� ❑ Distance to nearest lot line------------------------------------ ----------------- ---------------------------...-------------- ------- r.. Remodeling and/or repairing (describe):.----------------------------------------------------------------------------------------------------------------------_--------------._------ - ---- —-- -- - ----------------•--------------------------- ^............- ------a-----------------------------------•------_---------•----.....---- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordiBances, State w and rules and regulations of the San Joaquin Local Health District. (Signed)-- ' `` ?"^. .... ------------------___----------- -------------------------------------(Owner and/or Contract By---------------------------- -------------------------------------------------------------------------..(Title).----------_--- --_------------ - -----------... (Plot plan, showing sae of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENTUSE ONLY APPLICATION ACCEPTED BY ----- - -- --------------------------------------------------------- DATE.��------------------...................---------- REVIEWED BY--------- DATE.Nee - ------------------------------------ ----------------------------------- - -- - - BUILDING PERMIT ISSUED_.._...... � DATE__. ._--- - - - ` - - Alterations and/or recommendations:__-- --- -------- 2....t�Yt 2__Ct`__i�.�n___. _.. -I ----------- ty.. Yr1' 7 q� p' -f -- ------------/--L)Yrcl- p----= '-�l .i'l�i --- ----- fdl'�.-/- //----------------- r'f-:-----F-.Li. 'ff�--------�- -- -'- ----- --------------------------- - --- \" Qd.-`f0G0�_ _ 't ��' •. '" 4� ',�.XN FINAL INSPECTION BY:---- __ Date. -41 _1.A2..---6-/-------------------------------------------- SAN .- - --- SAN JOAQUIN OCAL HEALTH DISTRICT 130 Socfh American Street 300 Weaf Oak Street 132 Sycamore Street 814 North "C" Street Sfoekton, California Lodi, California Manteca,.California Tracy, California r // ES-9-2M . Revises 1.37 F-P.CO.