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liie� APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued 1W 4Li —Application-is hereby made t; the 'San Joaqun,Locak.,HTIth District for a permit to construct and install the work herein described,- This application is made in compliance with County Ordinance Nol 549. JOB ADDRESS AND LOCATION------ -- -- --- -- - -- --------------------------- -- --- ----------------- Owner's Name---- Phone_ --- - - -- - ----- -------- --- ---- Address---- -- ---------- -- -------- - --------------------- ------------------------- --- ------ -------------------- Contractor's Name---- --- - -- --- ----- -- - ---- -------- Phone Installation will serve: Residence ❑ A rtment House E] Commercial ❑ Tr 'er Court 0 Motel Ej OF Other -cip I. Number of living units: --- Number of bedrooms ___/._ Number of baths ---/__ Lot size ------------------------------------- Wafer Supply: Public system Community system El Private n Depth to Water Table��_ _ ft. Character of soil to a depW of 3'feJ: _Sand E] Gr-a7el E] Sandy Loam [j E] Adobe Hardpan E] 4C[ay Loam 0 Clay E] 111K Previous Application MaMaderYes,❑ NONew Consfruction: Yes No FHA/VA: Yes E] NOX I I - A TYPE OF INSTALLATION,AND,SPECIFICATIONS: IWi+hi L rm sewer is available n (No septic tank or cesspool pe' i�ted.�if pu61i 200 feet.) Septic Tank: Distance from nearest well,,,--2s-_-Distance fro foundaflon-A�'' M a t e r i a I --------- No. of compartments_ ,Z_.,__n_-_mak--_---__ Liquid clepth___�'e ---Capacit, r Disposal Field: Distance from neare'f wellN Distance from foundafion_/&__!-------Distance to nearest lot line__,�.4------ Numberlof lines--________ A of each lin ._e. _____________Width of trench______.1Zf ------------ I Type of'filter Depth'of filter ma'!'&ial----- -------Total length -;?0- ---------------------- Seepage PJ: Distance to nearest-rAweII_,v_4,_-,er-------15isfanceZ from=�"fp6ndatio'n--- ------------Distance to nearest lot Numbker!of pits_____!.__________- Lining mate ria -----S7e: Diameter__.__- Depth----AX9�_ .cesspool: Distance from nearest well-----------------Distance from fo dafion- -----------------Lining material__._______________________._________- ❑ Size' ;,Diameter-------------------------------------I Dept h------------------------V-------------------------Liquid Capacity----------------------------gal 1 . 0 Privy: DAVce from nearest well-________________________.________._____- nearest I;Nuilding---------------1-1-1---------------------- ❑ D , 01 Distance to nearest lot line_---------------------------------------- -------------------- ---------- ------------------------------------------------------ a:rd o r re iris',g (describe : -- ---- - -- ---I- --------- --------- _7 .. ...... . emode ------- ------- -- -------------------- ----- --------------------- --------------------------------------------------------I------------------------------------- I i I�19------------------- -------I---------------------------------------------- --------------------------I--------------------------------------------------------------------------------------------------- el------------------------------------------ -----------------------------*-----------------I----------------------------------------------------------------------------------------------------------------------------- I --------------- I hereby certify that I have prepared this applicati4n and that the 'work will be done in accordance with San Joaquin County ordinances, State laws, and'rules d regulafiopm Of fh an Jo uin Local Health District: % 9 [Signed} ---- - ------------- --- ------ --- ----------------- ------(Owner and/or Contractor) - By:----------- --- --------------------------------------------------------[Tit, --------------------- in six of cation of system in relation to wells, buildings, etc., can 6e placed on ever (Plot plan, sh 4 11 liicle}. #-,-'qZ--FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- --- ------------------------- DATE-------- -------- ------------------ ke....... ------------ ---------------------- ------ DATE------------V--- ---- ------------------------------- REVIEWED BY------------------------------------- - � _! BUILDING PERMIT ISSUED------------------------------------ y-------------------------------------------------------------- DATE._------------------- -- -:----------------- Aiterations and/or recommendations:----------------------- -----------I- --,,-- ------- -_-_-j----------------- ---------------------------------------1--------------------------------I------------------------------------------<-- -------- - - A --------------------------------------------------------------------------------- J - ----____V- --- --- ------------------------------------ ------------------------------------------------------ ----------------- - I ------------------------------------------------- ---------------------- -- ------ ---- -------------------------------------------------------------------------------------------------------------------- ----- - -------------------------------------- ------ -------------------- ----- ------- -- --------------------------------------------------------------------------------------------------------------------- FINAL INSPDate ----- ------------------------------------ --- SAN JOAQUIN LOCAL HEALTH DISTRICT 00 South American Street 300 Was+ Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1.57 F.P.CO.