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APPLICATION FOR SANITATION PERMIT Permit No. ._._��(_g . (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. i This application is.made-in compliance with County Ordinance No. 549./ =l'�e�Z��-r• ci c -v j' fi r ..C.'Y, co,Tr� RD-- �r� —33------ C� "' A 4 JOB ADDRESS AND LOCATION-- Q, UG sG G ---- ----•------- --------------------- ---------------------- -e. o --- -- --- --- ..-----_ _ Owners 'Name-------------------------- ------- _.-- Phone Address _ v. = r� .� --------------- Phone------- -------------------------. Contractor's Name----------------------------------------------- d Installation will serve: Residence X Apartment House ❑ Commercial I] Trailer Court ❑ Motel ❑ Other ❑ r L 44 x O F -- Number of baths f2- Lot�size --------------- Number of living units: ---I__ Number of bedrooms __ __ / _ Water Supply: Public'system El �Co m ity"sys erri 0 PrivateDepth•o TablO/6_ ft. j + Character of sail to a Ldepth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam (] Clay Loam Clay ❑+ Adobe Hardpan ❑ ] % s• I Previous Application Made: Yes> [T "Ne' Con�struction: Yes)<_No [IFNA/VA: Yes, No ❑. - TYPE OF INSTALLATION ANpY5PECIFICATlONS: fa (No septic tank'or`cesspool permitted if public sewer is available within 280 .)"` Septic Tank: Distance from nearest well__:� - Distance from foundation--._---_---_--__-- Mater l-_---------------------------------------¢-_. p Size IvxSx/4�--- Liquid depth -` Capacity----•--t- No. of compartments N Disposal Field: Distance from nearest Distance from foundation---ve- � O-f---Distance to nearest lot line-.---�---__- 6'0 �r Number of lines -.----- 9 n Length .of each Cine_____ ______________________.Width of trench--'-----_�----_ - . Type of filter material__--- -Depth of filter material.._.--V4?_ ------Total length--------- -----_------f¢ p g Linin material_______________ ______Size: Diameterf -----I-----.Distance to nearest lot line------ Seepage ---________'__� $eea a Pit:. N'umaber of-p nearest well F Distance from found : ------------------------Depth-----------------__-- -----=--{y g L Cesspool: Distance from nearest well-----------------Distance from foundation---I----------- ---Lining material-____---------------- ❑ --- --__----- Size: --------- Diter--------------- •---------:. I Depth-----------------,----------------- ---- -':-----Liquid Capacity----------------------------gals. rJ - Privy: Distance from nearestele_---_ --, Distancesfro«m nearest building-.--- ❑ Distance to nearest lot --------------------------------- Remodelin and or re? airing ---------------- --- � -----------------•--•'----------- ---"'------------------------=----------� ----------------------------------------- ---- 9 p g ------------------------------------ = ------------------------ ------- ----=-----------------•----------------------------------------------------- = = .. of that I have r-- -----'--=--------------------------------------------------------------------. -�-------------- ---------------- -----••-------•-------------------------- one.in accordance with San Joaquin Caun#y� I hereby certify p pared this application and that the work will be State laws!and rules and regulatiole of th San Joaquin Local Health District. f � ordinance, (J ------------- ( er and/or Contractor) --Own -- ---- r --------------------------- ------------------------------------------------- (Title) -- 3-- (Plot plan, showing sixe of lot, location of system in.relation to wells, buildings, etc._Can be placed on reverse side). r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------i - - -------------------------------------------------- DATE--# ` - .-1 DATE---.------- --------------------------- - ------ ' REVII WED BY ------------- - BUILDING PERMIT ISSUED----------------- ------ ------ DATE. € Alterations and/or recommendations:--= -- ------ -------------------- ----------------•-------- --------- { -----------•------------------------------------------------------- -=------ -------- ------------------------------------------------------------------------------- ---------•----------------------------------- -------------------------------- -------------•--------------------------------------- •------------ ------------ ---------------------- ------•----------------- ------------- ------- FINAL INSPECTION BY:------ -------------- Date Z `� SAN JOAQUIN LOCAL HEALTH DISTRICT 132 S carnore Street 814 North "C" Street 130 South American Street 300 West Oak Street Y �✓' Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M Revised 1.57 F.P-M