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1 � - 17`� APPLICATION FOR SANITATION PERMIT Permit No. --I-------------_Z 171y" (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 with Co'unnty Ordinance No. 549. JOB ADDRESS AND LOCA ION------1-33-`-j -- ----'---h`---- ------------------------------------------------------------------------------------------- i Phone- LhO �-(--- Owner's Name-`=�---�-V-�.----- -----------��-�-�-�- --=----=-----------------=----=-----------=---=----------=----------------------- i�--''--------------n�- -- Address-------------------------------•--------------al_153O------- - '--------------------------------- Contractor's Name--------------------------Qld .4-r----------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑❑ Trailer Court ❑ Motel ❑ Other ❑ " ' - ti3� --v� Number of living units:_/____ Number of bedrooms ---- Number of baths : _____ Lot size _____________________ ____________________________________ Water Supply: Public system ❑ Community system ❑ Private, Depth to Water Table -------- ft, I Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay_ Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes R;�o ❑ `FHA/VA: Yes ❑ No �r 1 1 TYPE OF INSTALLATION AND SPECIFICATIONS: �. (No septic tank or'cesspool permitted if public sewer is available within 200 feet Septic T nk: . Distance from nearest well-_ �6-.__--_-Distance from foundation_ld------------ k_LV_&0_&Material-_-_- ---_--__. ' No, of compartments.....-2 -----------Size--- k__`-�__'`._yj._____..Liquid depth-------J1. _ Capacity �._.----- ' Disposal Field: Distance from nearest well___r-...Distance from foundafii�n---/0_-f41�____Distance to nearest lot line-_,�---_-.----- W Number of lines_________ __ ______ ___________Length of each line----- GO-Width of trench.___(`---------------------- Type --.___---__-_______ Type of filter materia� ________Depth of filter material___� ��______..__Total length____________ _r'_ ________________-- See.a a it: ,Distance to narest well----yvinin materialDtace from foundation-ameter_.- K e topeea nearest lot line___�f_-r_-_ �1 P 9 Na i �'�i, Number of pits- --'�" g ��----------- LiningP-------------------------------------- Size: ------------- �. Cesspool: Distance-from nearest well-------------'--Disttance from foundation-------------------Liquid Capacity_ _-.-_-_gals. ❑ Size: Diameter------------------------------- -----Depth---------------- - Privy: Distance from .nearest well -------------------------------------------------Distance from nearest building------------------------------------------ I ElDistanceto nearest lot line--------------------------------------------------------------------------------------------z ----1----------------------------------------- i Remodeling. and/or repairing (describe) ------------------r------------------------- -------------------------•--------------------------------------- C - 1 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ N 4` ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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 r gulations of the San Joaquin Local Health District. {Si ned 9 )-y--------- -------------------- - ------- ----------------------------; i ` {Owner and/or Contractor By:------------------------------------------=---'-------------------------------------- '=-------------------------------------------{Title)---------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR RTMENVUSE ONLY APPLICATION ACCEPTED BY-------- -- --- - - ----------- - --- -------------==------------ DATE-------q- `- ---=------------------------------------- REVIEWEDBY-------------1 --`-`--------------------------------------------------------------------------------------------------- ----- DATE----- ---------------------------------------------------- BUILDINGPERMIT ISSUED---------- ---------------------------------------------•--------------------------------------- DATE----- ------------------------------------------------------- Alte Afoonss�anrd/or re-l�nmiendaf-ii.ons!:----------------- ---- s + (_am --------------------- ------------- ----_-------------.-F�-l4r�-� �?Nf� r ' � ...• _ •------- N pe ------------ /J -r'.`.l �{f'•+'1r �vr+�_ i (/1 ---------------------- -Tr-. f f t _ ------------------------ -- -_ - A° ♦ � Z--, - I �. n € '• { ` afT !4 i.�Y4. . .- rr ..i...^�h .- =.tis. to ' �S4filG4...r 9 ,..,.... ,�. 1F _ __i ----------------------------------------------- x? FINAL INSPECTION BY:----- - ------------------------------------ Date--- ------------------------ __- -------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 914 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California - r E5-4-2M Revised 1.57 F.P.CO.