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APPLICATION FOR SANITATION PERMIT Parm'l No. I . (Complete in Duplicate) rr Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descr&ad._-' This application is made in compliance.with County ante No. 549. JOB ADDRESS AND LO TION------------------ -- ------ --- = Owner's Name------------ -- ----- �Address------'-------------------------R-021-_ A--. • - Phone.: -__ Contractors Name............. . T, _. r --------- Phone - `� = Installation will serve: Residence partment House ❑ Commercials❑ Trailer. Court ❑ Motel ❑ Other ❑ �tf N — 0 Number of living units: /___ Number of bedrooms --c;7-- Number of baths ___ - Lot sizee-__XX0!7 . Water Supply: Public system [ ommunity system [:] Private ❑ Depth to Water. Table �W ft. Character of soil to a depth of 3 feet: Sand ❑_Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe E I-Hardpan ❑ Previous Application Made: Yes ❑IIINo 0!New Construction: Yes ❑ No [6y FHA/VA: Yes E] No ElTYPE OF INSTALLATION .AND SPECIFICATIONS: ' (No septic tank or'cesspool p!ermittedl if public sewer is available within 200 fee+.} e�fc TankDistan: r ce� from nearest wIell__ ADs#ja.n�t.e from found!aon___________ _ __Ma�#erial: No. of ompartmentsSz -c --------------------- e -----•---------------•- ----Liquid deP}h------- ------- - - i -------Capacity---------------------- Dis osa Field: Dstance fromnearest-well._-.___-.______-DiOance,from foundation to nearest lot line_________________ Number of lines....---------j-- -----------------Length of each line-------------------- --------Width of french-------------------------- Type of fitter material______----------_----__Depth of filter material------------------------ length_.____________------__________________--- Seepage Pit: D,istan e to nearest well_-_:-Distant m� _f�°J�ndation-./ --------Distance to nearest lot line__.- r, Number' of pits------- --__--Lining rna#erial_ d _ Size: Diameter-----�;3_"__-.Depth_..._- S----------------- 'l1 Cesspool: Distance from nearest well,____, ;-Distance,from�foundation.-._.___________..Lining material_____________________________________ Size;.Vameter-------I----=---------- -------------De th-------------- } 01 ❑ P -------------- - ---------------Liquid Capacity- ------------ -------------gals. Privy: Distance from nearest well__-_-._.--------.____-_.___-___-_I..............Distance from nearest building--------------.________-_--------------_- Distance to nearest lot Remodeling and/or re airin describe ----•-------------------------•-------•------- -------------------•--•------------------------•-•-•---- P i9 a , -----------------•---------------------•----- -------------------=- — �. : ------------------------------- ------------------------------------ -------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------- I hereby certify tha 'have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, a laws, les,and.r 4 ul tions f;+he San Joaquin Local Health District. �.. .f V (Signed) --- -- ............................... ---------------- - --------- 4� - caner and/or Contractor) By: ------------------------ (Title)-- r (Plot plan, showing size of lot, location of system i .re i n to wells, buildings, etc., can be placed on reverse side). s FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ---------------------------=---------- -------------------------------------------- DATE REVIEWED BY _ DATE -------------- BUILDING PERMIT ISSUED-..-------- -�-`-------------------------------------•---------------------------------------- DATE-------�r\ Alterations and/or regommenda+ions—)----------- --------------_•------------- -----------....------------•----•----------------•-----•00` hrr !✓, -----= --------------------- ----------------------------------------------------------------_--=-------------------------•-------------------------------------•------------------------------------------------------------- FINAL INSPECTION' BY:------- — ! > :------------- AN -AN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manfeca, California Tracy, California ES-9-2M Revises 1.57 F.P.CO.