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r APPLICATION FOR SANITATION PERMIT Permit No. ___-/.- ��---• tj (Complete in Duplicate) 5� . Date {sued 7 77 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 wit County Ordinance No. 549. T Y JOB ADDRESS AND LOCAT N___._t. __!_-- ----�p--- ' .,.._rI.. r.r.�,...,. ....� - okne.-W ---,=..1.- --R---- ------ Y- .____.__ _ Owners Name------ _---_"_-.-__---__ __----____.___q: `--------------------------------------------.--------------- ------------------------------- Address _ __ ---- _-____-___-___-_--____ Address_..------- ________ __--------------- ---------- Phone ---------- -- ____. _PhO E ------------- Contractor'sName_ .. Installation will serve: ' Residence. House El Commercial E] Trailer Court ❑ Motel El Other ❑ ot .,. I k Number of living 'units: _` Number of bedrooms - Number of baths _. c_ Lot size .__ -- - -------------- k ft.. . Water Supply: Public'system ❑-' Commuriity'system ❑.Private Depth to V+/ater Table _ _ Character of soil to a depth of 3 feet., Sand El Gravel ❑ Sandy Loam ElClay Loam❑ Clay ❑ Adobe ardpan C] Previous Application Made: Yes ❑ No New Construction: Yes ❑ No [I - FHA/VA: Yes ❑ No ❑-�" F TYPE OF INSTALLATION AND SPECIFICATIONS: k No septic tank or cess ool periff6d if pu6lic sewer is available within 200 feet.) i./- y ` = �:Mate6al �� Septic Tan : Distance from nearest well-_ -_'Distance from foundation_: ._ . No. of eompartments__ lSize_._ . _ f squid depth__. . CapacstYs'� 4 - --Distance to nearest lot line-— f Disposal Field: Distance from-nearest well-__�_�....t.Distance from foundation__ ..r # Number of lines---"��-,--. ---='§--- Len th of each line---- - ---!-_--------1Nidth of trench----- -e��_-________----__---- - -- g .......... Total length ff"- ' Type of filter materia!_l -- --- -- Depth of filter matenal___ _ _______. i _ ,.. Seepage P' rDistance to nearest.wel4 ` Distance fro fo dation__ v�d ___:.Qistance to'nearest lot line__.__ _ Size: Diameter_'�f De 'pits " ` 9 "Distance from foundation_,-- 4---- Lining material_ fh--- Number D stanceofiomsnearest wekl__Linin mDist.nce p---- Cesspool: t. _. .' F k -r R r F - -_gals. ❑ Size: Diameter = -----------------:-- ----- ----- - Ya------Liquid Capacity = ' = t__Qistance from nearest building--- ----------------------------------- ----------- Priv R Distance from nearest well-------------- l _y Y Y _ _ - -- ----------------------- ------ to nearest lot'line ----------- ----- - -- r 7 ...P j ------------------------- 7, -------------------- /fJ'`� 'r_ = 1 Remodeling and/or rapairing (describe)_____________ -------- --- _ ------ ------------------ ------- ------------ - ---- -- --- - 1---------------------------------- - ---------------------_------------------------ _______ __ _ ._ I hereby certify that'[ have prepared this application and-that the work will 6e-done in accordance with San-Joaquin County C ordinances, State laws; and rules andregal tions-of the San Joaquin Local Health District. r : w 5i ned Contractor) ( 4 } f CA (Title) 1� � (Plot plan, showing size of lot, location-of stem in relation to wells, buildings, etc., can be placed o avers side). FOR DEPARTMENT USE ONLY s +^- r -- APPLICATION'ACCEPTED BY--------------------- ----- _' -------------- DATE = REVIEWED BY---------- ------------------ - --- - -- -------- -------------------------------------`--- DATE ;-`---------------- -- BUILDING PERMIT ISSUED-------------------------------- = DATE------------------------ = - Alterations and/or recommendations ;------ ------ -------- ....... Y , --- - -- ----•-------- LL r --------------- _ _ _ Date v_' - --_- ----- --------- FINAL INSPECTION-BY:-.__-_�:. _ _�-= --- -- --------• ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Lodi, California ff. Manteca, California Tracy, California Stockton, California 5 i ES-9-2M Revises 1,57 F.P.CO. F