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----- AArl APPLICATION FOR SANITATION PERMIT Permit No. .__._ (Complete in Duplicate) Date Issued - -----/ cal Health District for a permit to construct and install the work herein described. i Application is hereby made to the San Joaquin Lo This application is made in compliance with County Ordinance 549• --------------------- ---- ------------ ------------------ � ------------------------------------------- JOB ADDRESS AND LOCATION--- _- f� -------- - � Phone- ------------------•---------- ----- Owners Name-----------? �-a ----•-----•--------•-------------•--------•- r .✓ r' • ---- ------ -------------------------•------------------------ Address-----•-------•---=- Phone----------------------------------- Contractor's ------- ----------------- Contractor s Name---------------- Other Installation will serve: Residence ❑ Apartment House ElCommercial C] Trailer Cour} E] Motel El ` Lot size _ _ - - -- -------------------------- Number of living units: _f -umber of bedrooms __ _ Number of baths -_-- Water Supply: Public system > Communitysystem ❑ Private ❑ "Depth to Water Tabled ft• PP Y� Y Gravel Sand Loam ❑ Clay Loam ❑ Clay,❑ Adobe I��Hardpan ❑ Character of soil to a depth of 3 feet: Sand ❑ ❑ Y ; Previous Application Made: Yes ❑ No 8"'New Construction: Yes o ❑ FHA/VA: Yes No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.] � s � " _ --------"Materia,__ '- '� - = --------------" Septic Tank: Distance from nearest well_..______-"Distance from foundation__; � *13 1- f -Li Liquid de fh--- ^-------------Capacity r No. of compartments------�c-------------Size_ :__ -- --7�- q p�,, e ,._ .� Disposal Field: Distance from nearest, well.._.__--"'�`'_..-Distance from foundation. �-- Distance toftfrench est ��e' Number of lines_____f------ " - ' ---Length of each line------ _------- Type of fi4ter material_ "-" - - DeP}h of filter material__ -----`--Tota4 length____-;� ----------- f ot 4' �' Seepage Pit: Distance to nearestwelL__.___ -----Distance om fou ndation---- ': -------Distance to nearest 4, -:-- Number of pits____ _------------Lining material--- rr�"' -ate Size: Diameter-_.-E- r ial ------- ---------- Cesspoo4: Distance from nearest well_____--_______-_Distance from foundation--------- --------Liquid Caing pacity----------------------------gals. ❑ Size: Diameter------------------------------ ------Depth------------------------------ ------- q p Privy: Distance from nearest well-------------------------------- r Distance from nearest building------------------------------------------ ❑ Distance to nearest lot line----- ---------------- ------- - <--------------------- ------------------------------------- Remodeling or repairing [describe :- t ! ---------------------------- Rem g and/ -----��.�r_ -------------------------------------------------------- - ------ ----------------------------------------------- ------------------- - I hereby certify that I have prepared tk-s application and that the work will be done in accordance with San Joaquin County .ons of the San Joaquin Local Health District. a-xr r � Owner and/or Contractor] ordinances, State laws, and rales an reg uai /J-. (Signe � A--�---------�---=----:'------- '--N-- '--�-- -------- ------- -•------- ------- --------- ------•------- ------------------------i = ' ------ (plot ----- , (Plot plan, showing size of lot, location of syste in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED _ _ DATE------------------------------ - DATE ---- -------- REVIEWED BY _.� _--- ------ -- ---- ------------- DATE --------- ----- ---------7-------- --- BUILDING PER1v11 ISSUED---------------------------- - -- -- -- ----------------------------- ---- w. --- --- -- -- ------------------ ------------------------- REVIEWED A erations and/or recommendations:_______----___ - - --- - ------------- ----- -------------------- -- -------------------------------- --------------- a --- --- ----------- ------- - --- --- 'A--_._ ----' -- -- -- --- . ----'---_. ----- Da .................................. - -- - --------------------- FINAL INSPECTION BY:----- - --- - ----- - --- -------------- a SAN JOAQUIN LO AL HEALTH DISTRICT 30D West Oak Street 132 Sycamore Street 814 North "C" Street 130 South American Street Trac California Stock+on, California Lodi, California Manteca, California y' ES-9-2M Revisea 1-57 RP-CO.