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} APPLICATION FOR SANITATION PERMIT Permit No. ,� � (Complete in Duplicated _ i ' - Date Issued Application is hereby made to the San Joaquin Local Health'District for permit to construct and install the work herein described. This application is made in compliance,with Countrdinance'No. 549. JOB ADDRESS AND LO , TION_________ ,z ` -------- .. - ----- Owner's Name 11_ => F= Y_- ----- - Phone - ---- Address -----------=--- -----Z-- ---- - - - •� ------------------------------------- = r r. 4. Contractor's Name- --------------- /� �C ! e-�� - - --- P hon Installation will serve: Residence 2--;A-partme 't House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other'❑ ,t Number of €ivin units: _______ Number of bedrooms Number of baths ____:__ Lot size Water Supply: Public system Commun'ify `system ❑ .'Privaf6'E] "Depth to'Wafer Table�6vft. Character of soil to a depth of 3 feet:}-Sand ❑ _. Gravel ❑'Sandy Loam ❑ Clay-Lo�❑ Clay ❑ Adobe E--"Hardpan ❑ Previous Application Made: Y�'e"E]-eNo ❑ New Construction: Yes ❑Uo—E], FHA/VA: Yes ❑i No TYPE OF INSTALLATION-ANDF5PECIFI,CATIONS: ,-(No septic tankor'cesspool permitted if public sewer is--available within'200 feet.) /,Septic 7arW-- Distance from nearest well-----------------Distance from foundationMaternal-.__------__ _ .-__---_--_--R- _.. No. of compartmeriFs_-- :5ize - -- :-- # - Liquid#depth--- I '------- Capacity------ ------------ +s iosal Distance'from.nearest'well 3.Drstance from fo kndation-_-_-_:� Distance to nearest lot line______ __________ Number of lines---------------------------------- Len th of each line----------------- -------: Width of trench.--_____.___----______________-_- g ►"Type of filter material-__ -------- ------------ --- Depth,,K.fi ter material----------- - ._..Total length------------------------------------------ 0 _---------------------------- ,Distance to nearest well / _ � ___D staisce fro foundation � > ``^ Datance to nearest lot line____ ...___ ' a#t^� 3 :r r I f Number of pits__---------------Lining material---___.___ _ _ . .Size.'Diameter-. •��-"�__---.Depth-__.--__.�' ----------------- Cesspool: --- ----------Cesspool: Distance from nearest well-_._:_ -------€-Distance fro ,foundation.-..-- :,_'-_ .Lining material_--_--._ -._------------------------ 2 :;Diameter_.:.---- ❑ Sizi � {� �----�-------IDepth:---__.=--:----------------------��=-� .----Liquid Capacity------------------ - -----gals. I Privy: 'Distance eEl ` Ditance from nearest building --------------------- ------------ Distance-to ---- ---- Distance to earetlot Ine._:.°_..' 'C'* --'-------r---------------------------I----------I------------------------------- ------ ----- -------------------- Remode4ing and/or repairing (describe):--------------------------- :-'--------------•-:-------------- R ---------- -------------------- --•--•- ______________________________ ___________________ -------------------------»__-_.._-___-__-___--___-___---_-__-----___-_--_-----___-._..-_--_-----.--___-----__-.---.---___--_--__--_---_--_--__--.- I hereby certify-That I have prepared this application and-fhaf the work will-be done in accordance with-'San Joaquin County ordinance State laws, and rules d re ulations of the San J�0 -71�7 cal Health District. } (Signed)_. t (Qwrr�r Contractor) :__. - ='`" ` `� _(Tifie}-- -------------------------------------------------------- By:(Piot plan, showing size of lot, location of system 1n relation toiells, buildings, eta,,, can be placed on reverse side). FOR DEPARTMENT USE ONLY' ; 1 APPLICATION.ACCEPTED BY _ DATE---Z------------ -----------• ----------=----------- REVIEWEDBY--------------------------- ------ - �` -:-------------- ---------`--------=----------•------------------------ DATE----�-------------------- - BUILDINGPERMIT ISSUED- ----------------------= ••------------- ------------:------------------------------- DATE------ ........----•------------------------=---------- A .erations and/or recommer�da ions:" x -_ _ ---------- ----- -------------- ---- < � _ --- _ ___ _ _' _ /meq{_ M1 _.__ Y_ ---------- --- -- -- ---- ----- - - -- -- ---- ---r—T-A_---- _.---••-------- 61-wa s �'z� -- "� �"�1 -- ----- - FINAL INSPECTION BY:-'- ` .J! ._:1 . . ...... Date - ---------- ----------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-7-2M Revisea 1.57 F.P.CO- E