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CATION FOR SANITATION PERMIT Permit No. .. �� D� N °, (Complete in Duplicate) �1 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 application is made in compliance with County Ordinance No. 549, JOB ADDRESS AND L ATION------, ,„_,, T_ .---- --- - /- �f�---------------------------- 7 ---•------------------------ Owner's Name -f � ---r- --------------------------=------------------ _Address . ."/ .._;. -- = Contractor's Name__________ ___ ' ____ _, r - ---�-� { ---------------------------------------------- ---------------------- Phone 7-•- 1 Installation will serve: Residence P,"'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/__ Number of bedrooms ___Number of baths __._ _'Lot size ___- Zr___ --------- ' ' - Water Supply: Public System Community ystem ❑ Private ❑ Depth to Water Table.5V ft. , Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam [❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ l Previous Application Made: Yes ❑ No J�,New-Construction: Yes ❑ '''No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS- � ,j (No septic tank or'i esspool permitted if publicesewer is available within 200 feet.) S is Ta Distance from near'est,well_----------------Distance from foundation--------------------Material________________________________________.______. oral F° Distance fropmrnear st/well--..____ _ Distance from fondationQld depth=.dist ce to neCapaci#y_______________________ ; #a l rest lot line_________________ , Number,of lines-------Y- �'yLength of each line------------------------------Wi44 of tre ch----------------------------------- Type of filter material__ Depth of filter material------rl '`_T�_.Total length____1__________________________________ Seepage P Distance to nearest ivefl___ Distance froom,foundation r_____-Distance to nearest lot line_.�_��_____ Number of its___ Linin material________ er___-- p p ----- g Sze: Dia met, De tri , I .w... Cesspool: Distance from nearest wells---_4_—,Depth ___----___c_Distance from foundation--------�______.Lining materia_ ___________________________________. ❑ Size: Diameter--------- -----------F-- -_ 4'—,Depth------------ I--------------------------------Liquid Capacity----------------------------gals. , Privy: Distance from nearest well--------------------------_----------------------Distance from nearest building-------------------------------.__-----._. ❑ Distance.to nearest-lot line--,..--_-----------------------------=------------------•-------= Remodeling and/or repairing (describe)---------=---------------- ----------'-----------------••---------------- ------------•-----_.-------------------------------------------------------- 3 ,- .t a ------------ .------------------------------------------------- -'----------------- I hereb cerci that I have prepared this application and that the work will be done in accordance with San Joaquin County ' ordinances, St to law ,, and rule 4nd re ations -of.the SSF2,Jpa4uin Local ealth District. (Signed)------A___-_aAAa----------- —' on#r ct ) -- -- -- --------- ------ - --- B - Y� •------------------ {Titla-------- r (Plot plan, showing size of location of system n re tion to wells; buildings c:, can place��in reverse sie). FOR DEPARTMENT USE 6NLY ` APPLICATION ACCEPTED BY'.----------------- --------- ---------------•---------------------•----------------------------:DATE------------------- y REVIEWEDBY------------------------ -------------- - - ------ ---------------------------------------------------------------- DATE /� . .._-' BUILDING PERMIT ISSUED------------------- - --- ---- -- --------------------------------------------------------------- DATE ----------------------- Alterations and or recommendations:__ ___ __ ----- 4-------------- ------ -1-•-- ---- ------------------------- -------- - - - -- - i -------------------------------------------------------- FINAL INSPECTION BY:. Date-/_/7-7----- ----- ;X SAN JOAQUIN 'LO HEALTH DISTRICT t 130 South American Street 300 West Oak Street 132 Sycamore Street 914 North "C" Scree} ;+ Stockton, California Lodi, California Manteca, California Tracy, California y ES-9-2M Revised )-57 F.P.CO. /