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APPLICATION FOR SANITATION PERMIT Permit No. ._�s_ ___L� —(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 herein described. This application is made in compliance wifih County Ordinance No. 549. .J JOB ADDRESS AND LOCATION:__ PS.7---------- 4--------h-4 ------------------------------------------------------------------------------------ Owner's Name s {► I-- --4- �b!�----- -------------- Phone Address------------------- A-1 4 ----- ------------------------------------------------------------------------------------------------------ Contractor's Name--------------------------- ------ ---•---------------- --------------------------------------------- Phone------------------ Installation will serve: Residence Apartment House I] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: T----- Number of bedrooms _ Number of baths ___/_ Lot size •-_____ Water Supply: Public system VCommun'ity system ❑ Private [❑ Depth to Wafer Tab€e-'/ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [❑ Clay Loam [] Clay ❑ . Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No [�KFHA/VA: Yes F No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitfed if public sewer is available within 200 feet.) i. -hc k: Distance from nearest well---------------_Distance from foundation--------------------Maferia)_________.____-__-______ ----------------------- No. of compartnlents--------------------------Size--------------------------------Liquid depth------------ ------Capacity----------------------- 13 Field: Distance. from nearest well-----------------Distance from foundation-------------------.Distance to nearest lot line-_-______________ Number of lines 1...___•--------------------------Length of each line------------------------------Width of trench------------------ -- ------------ Type of filter material------------------ Depth of filter material-----------------------Total length----------------------------------------_- Seepage Pit: Distance to nearesf well_- _ _--___Distant m fun da tion-----7_Q_......Distance tp nearest lot� line--- q V1� Number of pits._ _ '_________ __Lining material- Diameter____33__-�.___.Depth_-___�.�(_.____.___-____ ' Cesspool; Distance from nearest well---------- -___-Distance from foundation------------_-------Lining material-------- __----_._______________----__ ❑ r Size: Diameter -------------------- -------------Depth--------------------------------------------------Liquid Capacity- ---------------- -------gals. Privy; Distance from nearest well ___1--------------------------------------------Distance from nearest building_____.__-_-___._______ ❑ a Distance to nearest lot Eine Remodeling and/or repairing (describe):----------------------------------- -•--------•--------------------------------------------------- ' I .. --------------------------------------•-----------------------------------------------------•----------------••---------------------------------------------- I 3 I hereb that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinance , -tate la s, and rules and regulations of the San Joaquin Local Health District. (Si ned � g )------- frt'r .------ --- -------- -- --------------------------------------- ---------------------(Owner and/or Contractor) gY- =: --------------------------- ---------- - - --- ----------------------------------(Title) -------------------------------------------------- (Plot plan, showing size of lot, location of system in relati to wells, buildings, efc., can be placed on reverse side). r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- -' �-0 �,_ REVIEWED BY -------------- DATE--------�--------- 0 ------------------------------------- BUILDINGDATE PERMIT 155UED------------------------------------------------- --------------------------------------------------------- DATE 7--------- ------------------------ -------------- and/or recommendafio s:�________________________ ___ K ------------ ----------- -------------- ---- --- ----------------- -- ------------- :,--- -- --- - --------------- ------ a---•----------------------- I 1 FINAL INSPECTION BY:- -------------------------------- Date--- r------- -------------------f� SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M1 , Revised 1-57 F-P.CO.