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t/ APPLICATION FOR SANITATION, PERMIT Permit No. (Corp- in Dupli a e) �` f� Date Issued Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS RAND LOCATION------- j l � Owner's Name----.;; --- ---------------------- -------- --------------- Address-------- / o2------ ��. - � ------------------------- Contractor's Name g -x--- - ----------•-�------ Phone ----- installation will 'serve:- Residence AV,artment House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ Numbe`jf*fiving units: _ Number o=eedrooms _ or �c dumber of baths -�-_ Lot size � __._ ----------- Water 5uppl Publi system Community system �� f� y y ❑ Private ❑ Depth to Water Table ________ ft. Charade ;soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Ig Hardpan ❑ Previous Application Made: Yes ❑ No fK New Construction: Yes ❑ No 0 FHA/VA: Yes ❑ No's TYPE OF, INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted.if-public sewer-is available within 200 feet.) ��QQ Septic T nk: Distance from nearest well---A!!FAstance from foundation__f�-�_____--.Material_____-________________________ No. of compartments-------------- -----------Size-------------------------------Liquid dei? h--------------------------Capacity- isposal d: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line__----._________- �/� ! Number of lines., ----------------------------------- of each line----------------------------- Width of trench-------------- ---------- Type of filter nilafeerial___________________ __Depth of filter material__________________ ____Total length---------------------------------- Seepage ________________._________ ____ r Seepage Pit: Distance to nearest well__Iec d _.___ _ __Distance from f undation__f�_.Distance to nearest lot line__. _�� Number of pits..--___-/-----------Lining material_-- ___.Size: Diameter__-_3_& ------Deptn___--ca� -�r___ _ Cesspool: Distance from nearest well--------------___Distance from foundation____________.______.Lining material_____._-_________-----_______________. i �1 ❑ Size: Diameter--------------------------------------Depth--------------------------- Liquid Capacity gals. S Privy: F 7--•Dist.ancerfruiT)ne4as+-well------------------------------------------------Distance from nearest building-----------------------------_---------._. ❑ �Pisfance for nearest At line--------------------------- -- ------------------------------------- RemodeliIp ---------------------Remodeliln and or e airs describe :___.____ _ __ -- �^ . p; 9 r( 3 I ) ` v /, ---f ----------=rpm------------- ---- -?4- ----- ---- -=3-?4 X- f-- _f----------------------------------------- -------------- -----------------•-------------=-----------•-------------------...--------------------------------•--- ----- \ _________________k�_____________--_--_______________________---______+-------------------------- _______________..________----________..__-_-______________-_.______-_.________-____________________.________________..._--- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws and r es and re4ulations of the San Joaquin Local Health District. , Y (Signed) ---•------- - ------------------------------------------------- --------------------(Owner and/or Contractor - •--------- Title (Plot plan, �Aowing size of lot, location pf�sterr� i� relation j;k.welis, buildings, etc., can be placed on reverse s:1f , ,�.S..T, FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- t - -+ r------------------------------------------- y� -------------------------- DATE---------=/-----` REVIEWED BY ------------ -- ----------------------------------------------------------------------------------------------------- DATE BUILDINGPERMIT ISSUED-------------------------------------------------------------------------------------------------n- DATE_.--e!---------------------- Alterations and/or recommendations__________________ 4 ---•----- -----------------•------------------------------- ----------------I--------------------�`'l ...---� :: T.r1---------X93-----------G'°K'----•------ f �- --------------------- ---------i----- ----60 AF-0------kfFACH °wNafZ W_STA"1Ex> --t- . �aNfV�� r� -----•----5 -------- r ' --------------------------------I------------ -------------- F1NL fNSPlO �G -=�-� -- --------- -� ---�--- ---• - - - Date------- �----�-- SAN JOAQUIN LOCAL HEALTH DISTRICT 134 South American Street_ 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California• Lodi, California Manteca, California Tracy, California ES-9-2M Revises ;-57 F.P.CO!