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s / APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued /4 I x-40 —4 Z 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. f t' r +.v= JOB ADDRESS AND LOCATION-.:-- --- i 1.90 /,t-,J7�V',�pfl_E s,•`` ri e� �,t, --- , 11 \i w , &. or\ i Li�4G. Owner's Name b-------dD_..-------• 0-�---oTL'--------------- --------- Phone--------------------- ------- ----------- - Address - - fs _ •, 'Tet-C4__�'J�:n',p�X„ Contractor's Name-------------------------- -- Phone ------------------------------ - ----------------------------------- Installation - -- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Ej Other ❑ Number of living units: --i----- Number of bedrooms _7--Number of baths __f____ Lot size -------- Water Supply: Public system ❑ Community system ❑ PrivateX' Depth to Water Table _ ft. ,1' Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam m ❑Clay Loa ' Clay E] Adobe F] Hardpan ❑-CZ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool-permitted if public sewer is available within-200 feet. ) l Septic Tank: Distance from nearest well-,-!2 y-----Distance from uid dfoundation-._-/G_f____-Material____ _�_ �s�±"L---- - i 4 No, of compartments-_____�� _ . "_._------Size_____ __ ��JC, _Li e fh_.___ -Ca Capacity q p p tY '-z Dia os I Field: Distance from nearest well_-S __-_Distance from foundation____ b________-.Distance to nearest lot li `"'_- Number of lines------------`_2�`�__'__`__________Length of each line_______ _:_& _ -------Width of trench_.__�_��_ii ------ Type of filter material___- # EDepth of filter material_ ------ Total length_________________ _I -I____ Seepage Pit: Distance to nearest well---_------------------Distance from foundation--------------------Distance to 'nearest-IotAine 171Number of pits._t-------------------Lining material----------------------aize: Diameter-----1*------------_-Depth---------------------------_----- Cesspool: Distance from nearest well-----------------Distance from found`a tion--------------------Lining material---------------------.___________ ❑ Size: Diameter------------------------- -- ---------Depth------- Liquid Capacity gals. Privy: Distance from nearest well__________________________________._______.__-_Dist nce from nearest building------------------------------------------ Distance -____.._____.___--_ -_----------------- Distance to nearest lot line-------- ----------------------------- -------------Ic-'------------- Remodeling and/or repairing (describe)_________________________ --------------------------------------------------------------------------------------------- --------------- ------------------------------ ----------------------------------------------------------------------------------------------------------------------------•--------------------------------- ----------------•----------------------------------------- ;--------------------------------------------------------------••-------------------------------- ------- --------------- -----------------------------=------------------•------------------------------------------------------------------------------------------------•------------------------------------------------- I hereby certify that I have prepared.this application and that the work will be done in accordance with San Joaquin County ordinances, Sfatell4ws, and rulerand regulations of. the San Joaquin Local�Health"District. {Si ned - - --- 9 } = ' ' .�/� _ ---------------------------------= ---(Owner and/or Contractor] $Y:------------------- ----------- -----------------------------------------------------------------------:77777----------------(Title)-----------------------------------------------------�..."�, (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 -- ----�` '--- ------ -------------------------------�f------------------------,DATE------- ------------- REVlEWID BY ------------------------------ - ------------=-------------- ----- '---------------------- DATE BUILDINGPERMIT ISSUED-------------------------------------------------------------------------------------------------------- DATE Alterations and/or recommendations----------------------------------------------------- --------------------•--------------------------- _______________________________________________._____________-_________.__________.___--___--_..__________________________}.-_____________._________-_______-_-.._._____-_____________--______________...___________________ _________________________________._____________._._______.__.______-_____._.____-.._______.___________..________-.-____._____.___________.________-____.__________-______._____._____________________________________-----_____ ------------------------------------------------------------------------------------- ---------------------------------------------------------------------------- FINAL INSPECTION BY:---------- -------------- Date------ Jr SAN JOAQUIN LOCAL HEALTH DISTRICT t � 130 South American Sfreet 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ' ES-4-2M lRevisea 1-57 F.P.CO.