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r APPMATION FOR SANITATM P1IRMIPermit No rbv*efo in Duplicate) Date Issued / fM/!:T:.., Application is hereby made to the SanJoaquin Local Health District fore ermit to construct and install the ribed, This applica# is mettle in compliance with Ccarity_Ordinancb Mo. : JOB ADDRESS AND LOCATION Owner's Name........ .......... *'r-,.....: r. . . t . l Address-----•- .....: .-- .__---. �_...r ._.1 }.. :i� Contractor's Name-.. hone Installation will serve: Residence (Apartment House.0, Commercial ❑ Trailer Court C1 Model r!" 00W ❑ Number of(wing units: .::. Number of bedrooms . "'Klumber of baths . size _. ;e �_ .- Lot- Water,Supp y: Public system n Community p Private epth to Water Table d ft " Character of soil to a depth-of 3 feet: Sand sY Gravel ❑ Sandy LoamCIaY Loam ❑ Clay`❑ ' Adobe Q Hardpan ❑ Previous Application Made: Yes ❑ No Now Construction: Yes W _ No ❑ FHA/VA:'Yes TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic-tank or'cesspool permitted ►f p>Jblrc sewer is available within 200 feet Septic Tank:; Distance from Hearers# weN.. .......Distance rerom foundation. _ ..._.._:Mate Materiall No: of compartments-__ _', ..---------Size__,2' -� m.t . d Liquid de}th_, AL1... -_______:CapaCify,.lcl ,. .: Disposal Field: ' Distance from nearest well. -_.. Distance from foundation j—&- .. �'Distano to nearest lot line 3.!X '� Number of lines .'. Length of each line__.__ ;��, 'Width of trench �° Type of filter material:. i pth of filter material.. ,..._Total, length_ :. _Q ....,:_ ....:..: Seepage Pit; , Dista ice.to nearest well.......................Distance from"foundation......._ ...... .Distance to noarbst lot line- -• Its [ p Nu(n6or of. pita dining material....... ---"Size: Diameter.-- ......_.Re{3tli......:: Cesspool: ti t)isfance from nearest well-..._. __...:Distance from:foundation....................Lining;metetial. ........ _ .......... ....... El "ze� Dtx�er = ALiquidtpasty gals. Privy: Distance from nearest well__-----------------------------------------61s , � ❑ Distance to nearest lot line:__.. ---------------------..----- - ------- -----. ............. . •---- .................. Remodeling and/or repairing (describe)_____ ......... ... r.,. _. ----------.....................................<...... .............. . .......m::.....Y:.�� .- - ..................:i •----.. ..: ......... ...+-- -- ----- hereb carltify that I have prepared this eppli tiei+ and #+at the work will be dens +n aaaordance WA San Joaquin Courhy ordinance a laws, and rules &stl. re�j �f�ihd Sarn Jgequin Local Health Distric#. (Signed{- - �'-` - - _ . -- �Crr�er aeccf f or Contractor{ t By------------------- ....... ....._.. .. ...... .._... .........1-� --.................................(Tiju).............. ..................�:... ._..._ {Plat plan, showing sae aft #„location of system in refiet on to• cells, buiMings, etc.' can be.,plactid', reverse side. APPLICATION ,ACCEPTED BY..--• -- -.,. .:. ::.... . . DATE..�`�- _1_ ~ . ....�: ---------- REVIEWEDBY-----.............................. __. _= ----•-..._ DATE------... .... ........ .......... ........ BUILDING PERMIT ISSUED: ---- .....:._ ...._.......... ........................ ._'D ►ft: .,..:..................., Alterations and/or reoommendatians ... ::..._.�.,...........-•...... -•--:�., ,_...�_._.�.. ........... ........ ................,? ...._.................................................................r �,. FINAL INSPECTION BY:...... ...... ...--•-------•--- Date.-'---------..._ __............ .. ...................... SAN JOAQUIN LOCAL HEALTH DISTRICT 330 South American Street 300 West Ook Strait 132 Syumon Street $14 Norlf+ "c`t Street Stockton, CaliforniaL=ath, California Manteca, calsomfe Trsay, California FS-4-2M , Revised 1-57 F.P.CO.