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2 ,0 yV V APPLICATION FOR SANITATION PERMIT Permit No. ___________ 4 (Complete in Duplicate)b / Date Issued --------l-10 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 AN 7 LOCATION___•---- ---__-- Owner's Nam ------ - r-------7-1...141----------- .._ � -- �on _ ------------------ - - - -------------- _ 0,0 .... Addres ..... Contractor's Name --------------- Phon ---------------------------------------------- Installation will serve: Residence Er ; partment House-El- Commercial-❑-Tra-ilef' court 'El' Motel ❑ Other ❑ Number of living units. _ Number of bedrooms-2. Number of baths Z2- Lot size - ___e -------------------------- Water Supply: Public system ❑ Community system ❑ . Private [P-15epth to Water Table4ld- ft. Character of soil to a depth of 3 feet Sand ❑ Gravel ❑ ' anciy Loam ❑ Clay Loam [I Clay ❑ Adobe �ardpan El Previous Application Made: Yes ❑ No New Construction: Yes ❑ No M1-_'FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.)r - tick: Distance from nearest well _______________Distance from foundation-------------------Material_._.__.____ No. of compartments_. Size--------------------------------Liquid depth--- --------------------Capacity-------------------- i Number of lines-------- /_ Length of each line____. Distance to nearest lot line.. ______ V `f sposa ie Distance from nearest well. _- -- Distance from foundation---__ Width of trench_.__ _ t Type of filter mate riaL_Is1_ _Depth of filter material_=-__,/,V-------Total length------------a-0.1__________________ 5eepag Distance to nearest well_JA!�__.____.___D;istanc om undafiion----- A........Distance to nearest lot )ine_ __ Number of its---- ---------- p Lining material_ j- - Size;f Diameter_-- `1 / r � �-��4 -,' ---.Depth --��'-- - ---------- O Cesspool; Distance from nearest well_________ Distance from foundation--__-____.-l___-----Linin material_.-_------_______----_---_--____--. a t ❑ Size: Diameter--- --------------------------------- �-r------�'-' ------------1--- .'a='-'--.Liquid Capacity-. gals. tN Privy: Distance from nearest well_-.________.___..__I_ Distance from riearesfi building ---------------- El Distance to nearest lot line__ - " Remodeling and/or repairing"(describe)------------------ e ---------------------------•------ r --------------------------------------- ------------------- ----------------------------------•------ ---I•-•----------_------------------------------------ ------------------------------------------------------------------------------ I hereby ceWN that I have prepared this application and that the work will 6e done in accordance with San Joaquin County ordinances, St r f1tyws, anA rues and re tions of the San Joaquin Local Health District. _ (Signed) �/ -'�""=--------� I (Owner and/or Contractor) $y:. {Title `'^�f - - ----- ------- -- -- --------------------------------- (Plot plan, showing size of lot, location of system in. ation to wells, buildings, etc., can'be placed on reverse side). r 1 FOR DEPARTMENT USE ONLY [ t APPLICATION ACCEPTED BY-------- -- - ------------------------ ---------------------------------------) DATE --- EW ED BY ---- �-----•---- -------- -- s.`DATE" ----------- - UILDING PERMIT ISSUED---------------------------------- - ------------------------ DATE - --------------------------------------- ------------------------------------- Alterations and/or recommendations--------- ------ ------------------------------------------------- ---------------------------------------------------- ------------------------------------------------------------------------------------------------------ ------•------------------- ------ ---------------------------------------- -----------------------•------------------------- - -- - ----------------------------------------------------------------------------- I FINAL INSPECTION BY---------------------------------------------------------=------ Date------4 -7/ -------••-- SAN JOAQUIN LOCAL HEALTH DISTRICT 3 130 South American Street 300 West OA Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revises 1-57 RP.CO.