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a, APPLICATION FOR SANITATION PERMIT Permit No, !Lt?-1.7._--..- (Complete in,Duplicafe) Date Issued Application is hereby made to the Sa/Joa9"i, 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 AND LOCATION, Owner's-Name -----•---- --- - ----------•-- ---------- •- . Phone--------------------•-•-- Address--------- u� Ir•�"�' � - - - --------------•- Contractor's Name •----•-------•-------------------------------- ------------------- Phone.----•---•--------•-•---- Installation will serve: Residence t❑, Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: ---+---- Number of bedrooms ---1--- Number of baths -------- Lot size ------'I1---J-0--_-_--_-_ ----------------------- Water Supply: Public system 14 Community system ❑ Private ❑ Depth to Water Table .16d-- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam (2 Clay Loam ❑ Clay ❑ Adobe E] Hardpan E] Previous Application Made: Yes ❑ No ❑ New Construction:"Yes ❑ No ❑ NANA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: p No septic tank or'cess ool ermittedvif public sewer is available within 200 feet.) ��- .� Septic Tank: P Distanc`�e�f oom-Pearestwwell:.d`Ds!J p ante romf foundation , '"�terial_� _ t No. of compartments__ ° -Size_1?t7�'T--------------Liquid depth-----�----- -----------Ca aci Disposal Field: Distance from nearest well/-_�'____Mstance from foundation Zr7�_------ er of / _-_.Distance to nearest lot line-- b�_-•_--- Yp �. - _ p ach line---��'-------------------Width of french...'"�L f Tu Typeoffilter materia Denghhofff`rifer material__ '!_-______Total length--�Q' •__--_- --- Seepage Pit: i Distance to nearest we I---------------_-----Distance from foundation------------........Distance to nearest lot line----------------- Number -----____------ ❑ Numb er- f pits---- I---------- ----Lining material----------- --------,__Siz b: Diameter-------------- --------Depth--------------------------------- Cesspool: -------------------------------- Size: Diameter--------- - ------------ _�.Qepth�- -------- ---------------------------------------Liquid Lining material-------------------------------------- F-1 - f�m foundation It Liquid Capacity __gals. ass oo : istance ram nearest-well-_-------__.-._ Distance Privy. Q stance from. nearest well-_-_------_-----------------------_-------.-.._Distance from nearest building--------------__-----_ ❑ Distance to narest lot line -------------------- Remodeling and/or repairing (descrilje)------------------------------------------------_ -----------------------------------------------L-------------------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 ws, and rul s and regulations of the San Joaquin Local Health District. (Sign --- ----------•------ ner a– _-�O_ ----------- ---- ----------- ----,------�------- ------------------------- ----------------- ---- ca BY:-------------------------------------•---------------------------------------------- -- -- 4- - ---------------------------(Tif le)---- ------ (Plot plan, showing size of lot, location of system in.relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- DATE f' --`� ----------------- ---•--------------- REVIEWEDBY ----------------------------------------------------------------•-------------- DATE..... BUILDINGPERMIT ISSUED-------------------------------------------------------------—---------------------- ------ DATE Alterations and/or recommendations:---F------------------------ ---------------------------- -------------------•--------- --• -------- ----------------------------------------------------------------------------------------------------------------------------------•-------•----------- ---------- ---------------------------•---------------------------•------- •- -------••-------------- --•--------------- FINAL INSPECTION BY., G. ,� - Date -~ ,_3-_ F SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California j Lodi, California Manteca, California Tracy, California I ES-9-2M . Revises 1-57 F.P.CO.