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APPLICATION FOR SANITATION PERMIT Permit No. (Cornplete,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. This applicdtion is made in compliance with County rdinance No. 549. JOB ADDRESS AND LOC-�ATIOt�.__--�-Z-__ sZ�6 I ----------=- Owner`s Name- -- --- - -------------- --------------------------------------------------- r � -- --------- --------------------------------------------------------- Phone Address•-- ------------------------ ----------------------------------- `� `' -=�- • . ----------------- on rector s .Name_-- --- --------------------p------•-------------------------------------------------- -------------------------------------------- Phone ------- Installation will serve: Residence M A artment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Othe f E]Number of living units: 'umber of bedrooms -J.. Number of baths J- Lot size --- Q_ �{ tt Wafer Supply: Public system V Community system ❑ Private❑'"Depth"tc Water Table - ft--� Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam , Clay Loam El Clay [I Adobe ardpan ❑ c Previous Application Made: Yes ❑ No QNew Construction: Yes e No ❑ FHA/VA: Yes No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if p bl�c sewer is available within 20 feet) Sept ic�Tank: Distance from nearest wello, � r r t + - _ istance fro foun ation_ - • j- �- Maters lr --- --- ® Na, of. compartments------------ - Size_ a_- - ------------, .'" E -- Liquid, epth - ;Ca acit DisposalfField: Distance from nearest well�� +stance -X a ) P y � r •- -- � � rom foundation ---.Distance to nearest lot line- ----_--- Length of each fine--------- ---------- TypeNumber of lines----__--___ � _ _>� Width of trench---.-___�i!t�"`r. - Type of filter materia�J +�it l pe th of ' -- p iter material :[ ... Total length-=------. �--------------- epage Pit: Distance to nearest well-----------------_---Distance from"fouri'd.6 ion_--.._-__--_--.Distance_ Distance to nearest [of line----------------- e' ❑ Number of pits Lining material-----------------------Size: Diameter------------------------Depth-------------- �`Cesspool: Distance from nearest well---------------- Distance from fou elation_--_-__----___ `v El - -.-__.Lining mafierial------------------- Size:.Diameter--------------------------I-------------Depth--------------------- - .--- -------------Liquid Capacity--, -------------- - ---gals.Privy: Distance from nearest well--------------"------- ---------------------------Dis-tance from nearest building---------'__y----------- •-__ 11 Distance to nearest lot line__----------------------------- x - ----------------------------------- Remodekng akd or Lrepairin (descr'�,b k + -----------•-------•----- --- --------- •------------------- - ------ - ---- --- - ''� - I f ------------------.:ice--- ------------••---------------------------------------- ----- -•-----------•--------------I---- -------------------------------------------- I hereby certify tha,+A have prepared this.application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. {Si ned g S r * -{Owner and/or Contractor) , By:------------------------------------------- = (Title)------------- ----------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings; etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY ----_-_. ! E DATE --------•------------------------------------------ REVIEWED BY------------------------ - -------------------- ----------------- DATE---,- - 9sjij_D!N PERMIT ISSUED, ---------------- ------ DATE- -- -- -------------------------- A[#eratior. and/or recommendations----------------------------------------------- - r ------------------------------ =a �X ..... s4�5 n----Qu.7-x� --------------- Q F �'•..� J .. -t ---------------------------------------•------ --------��tVV ate•- �---- ---------- 1-�._ - G' -------------- -------- �-- -Z-----. = -------- ------------------ FINAL INSPECTION BY:.:- Date----------- -I" ---- --- --------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street Y r 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-21x1 Revises 1-57 F.P,CO- f