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'APPLICATION FOR SANITATION PERMIT Permit No. ....-7S. � 0� 4 . —6d -(Complete in Duplicate) Date Issued ___-------- -______-- This Permit Expires 1 Year FromtDate 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 with County Ordinance No. 549. 1 i+ --- -------------------- ------ ` ------------- D 'CATI / /JOB ADDRESS ANPhone ------------- --------- - ---------- Owner's Name------------ . _40-------AddressP hone----------------------------------- rContractor's Name Installation will serve: Residence Apartment House ❑ Commercial I❑ Trailer Court ❑ Motel [I Other C3�! I ' 4 Lot size __Df '�l ---------------------- Number of living units: _. Number of bedrooms __ �' Number of baths --1 Water Supply: Public system Community system ❑ Private ❑ Depth tdWater Tablet+. k { Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0`Hardpan ❑ Application Made: Yes ❑ No New Construction: Yes ❑ No 5D®FHP+/VA: Yes E�-�o ❑ Previouspp ii TYPE OF INSTALLATION AND SPECIFICATIONS: !` i (No septic tank or cesspool permitted if public sewer.is available w�ithin 200 feet.) r v t - Matri�a� ��® /� Septic Ta k: Distance from nearest well__a ;_ ---Distance from foundation______ :_ it � ----Size_e_0/1 - Liquid depth Capacity..- No. of compartments---- � e � Disposal Field: Distance from nearest well��r ___:-.._pistanee from foundation___,C --------Distance to nearest lot I'ej_ ' Length of each line---- Width of trench._ _�.-------------------• Number of lines--_-__-- f_--- ------ g �p De th of filter material 40 Type of filter materia -`----Total length__._- :---•=--_-- L.��_� P _-__.-__-Distance to nearest lot li�ne___----- Seepage�Pit: Distance to nearest well__ ��-- -Distance fr foundation____ Q De Number of pits______ ____________Lining material--- .Size: Diameter;, _ --- p Cesspool: Distance nearest well�_ ___ Di_�tance from foundstion_--':---- Li'nuid Capacity______._________.;__-____-gals. ❑ Size: Diameter------------{------------- --- --- -Depth-- ----- q a I----Distance from nearest'building------------------------------------------ Privy: Distance from nearest'well-____---___-__.- �l ❑ Distance to nearest lot line--------- -------- Remodeling and/or repairing (describe):-------------- F ---------------=--- ___________________ ______.-___________ _>. ---__ _ -_____________-- _--_.__- __-_____ -------- _; ___•____-•--- •------------------------------------------- ------ u�' y 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, r� ! tr Contractor) (Signed)--------------------------------------- BY:-----------------------------------•---------- ----------------(Title)----- - ------------------- --r- ----- - -------- (Plot plan, showing size of lot, location of syste n relation to wells, buildings, etc., can be placed on reverse side). -FOR'DEPARTMENT LlSE ONLY DATE------------- - APPLICATION ACCEPTED BY f ' ----------------- DATE REVIEWED BY------------------------------------------------ i� BUILDING PERMIT ISSUED------------_-------------- -------,---------- ---------- ----- QA�'E-- - --------- -----------= ---------- ---------- --- Alterations and/or recommendations:---------------------------------------- - -• ---------------------------------------------- i - ------- ------- --- - ------ ------ 14 FINAL INSPUt N BY -- . Date... l--M- ----- -- --- SAN JOAQUIN LOCAL HEALTH DISTRICT `. t," ,r 13 Sycamore,5trea+, "' J 814 North "C" Street 134 South American Street 300 West Qak`Streo#, ��,,� Tracy, California Lodi, California Manteca, California � Stockton, California , ES-4-2M Revised 8-'59 F.P,Co. ,._.....�