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I APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) �1 Date Issued .----�-�5__-�-- Application is hereby made to the San Joaquin Local Health District for a permit to construct and instal€ the work herein described. This application is made in compliance-with County Ordinance No. 549. JOB ADDRESS AND LO TION Owner's Name-------------rq- .• --------------------------------------------- --------;------------------ Phone----------•------------------------- Address-_-------------------' Contractor's Name -- 'vo---`-----� - Phone. Installation will serve: Residence 0`-A-partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ • .r tie r- 4 Number of living units: __/`__ Number of bedrooms __ _ Number of baths __ __ Lot size __x---f� __ _______________ Water Supply: Public system ❑ Community system ❑ Private [91�Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[rfardpan E❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No PR-`1HA/VA: Yes ❑ No N--- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.)! Septic Tank: Distance from nearest we - _ -----Distancefrom foundation__/�Y..----------Material_____[ _ ___ „ .-- --. [ No. of compartments___ ---- -------_ Size__Jl�_�Xg6 'Liquid depth_____r Capacity----Xj+��__..__ p Distance from foundation---a�_j_1___-----Distance to nearest lot line ----------- Number .-______ Dis asal Field: Numberof lines earest well _-_ ength of each line___ w_f__!�_,_07� vidth of french___.-_ ____________ t Type of filter material of filter material_;__ _ _?!.-_Total length_____ __________________ Seepage Pit: Distance to nearest well---------------------- from foundation--------------------Distance to nearest lot line_---- -------- ❑ Number of pits----------------------Lining-material----------------------.Size: Diameter------------------------Depth---------------------------_-__-- \k I Cesspool: Distance from nearest well_________________Distance from foundation-------------------.Lining material---------...------------------------- ❑ Size: Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals, 1N Privy: Distance from nearest well _______________________________________________Distance from nearest building------------------------------------------ L1Distance to nearest lot line--------------------------------------------- --- ---------------------- --- ---------------------------------------------------- Remodeling and/or repairing (describe]:--------- 1 _ r ` �. -----•-----------------------------------------------------------•-------------------------------------• - --.....-----------------------------------• --------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------- --------------------------------------------------------------•------------------------------------------------------------------------------------------------------------------ r 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 rul s and regulations.of the San Joaquin Local Health District. (Signed)------------------- - ---- - - -------------- -- --- ------ - -____-- (Ownar�snt4-/�sr Contractor) --- --- ------------- -- ----- - ------ -------- BY - r/ -�---- -�----------------(Title) •-� �'�-' (Plot plan, showing size of lot, location of s m in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY , APPLICATION ACCEPTED BY- r.'F_.Q:!---------- ------- ----------------- ---------------------------------------- DATE------ REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE----------------------- ------------------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------- DATE Alterations and/or recommendations---------------------------------------------(----------------------------------------- �-------------0--3-K- ----------------------------------------------------•---------- r ------------------------------------------------ ................................ ------------------------------------------------ - - - ---------- - ---------- Date WSPECTIOIJ 6Y� Date-------- / - /- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore $free+ 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California £;S Revisea 1.57 F.P.CO.