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• APPLICATION FOR 'SANITATION PERMIT Permit No. (Complete in Duplicate) r/ a Date i D d �- Application is hereby made to the San Joaquin Local"Health District fora permit to construct and install the work herein described. This applicationis made in compliance with County Ordinance No. 549. JOB ADDRESS AND-LO ATION--}-- -- - --`--- -r � ----- -------------------------- -- --------- Y Owners Name_ ----- _. Phone - - ... �---• ----- Address---- Contractor's ddress--- = _{ -^ I _ Contractors Name- r - ''' . "`• hone_ Installation will serve: Residence iApartment use ❑ Commercial ❑ Trailer Qou'rt ❑ Motel ❑ Other ❑- Number of liven' pp ' Number,of bedrooms �--. Number of baths"_ -- Lot size .---��----- -------------------- - trj-, � Water-Supply 'Public'system'❑„"Comrhunity system ❑' Private��;-Depth to Water Table .,: Character of soil to aJdepth of.3 feet:. Sand ❑ ' Gravel ❑ Sandy Loam ❑. Clay Loam [p Clay AdobeX/Hardpan ❑ Previous.Applica+ion Made..�Yes4❑k No New Construction: Yes No ❑ FFiA/VA: Yes No� Y ' TYPE OF INSTALLATION AND.SPECIFICATIONS: f (No septic.tankForYcesspool permitted if public sewer is available within 200 feet.) y. _ eptic ank: '' -Distance from,neares# well______ ________'Distance from foundation___:_________ _____.Material___.__:__..__"__._-_------- -...` Nze .;occ f opm�nea est well-----------------'.DI sten Liquid depth Capacity - _ `f Dispos eld: Dista a ...__.Distance to nearest lot line____ ce from foundation_"___:._____ - Number of lines"-':'---------------- -Lengtii of each line-------.------------------.----Width of french----------------------------------- . . . TYpe of filter rnatenial____'-_---c---------------Depth of,filter material----------------- -----Total length-----------.------------------•------- t -- -- •-- Seepage Pit: Distance to nearest well'- �Q '_Distance from f ndation= C� ��- ____.Dist,��e to nearest lot line_,� _�."-.. ., Number of pits_" .° __Lining rnateriaL Size: Diameter___�g2__._.__ ____.Depth-- Cesspool: Distance from newest-well;" _ i Distance from foundation > 'Lining material_______________ _________________ Size: Diameter ---- -� ------- !Depth------------- •, ----•- ---- -- i -Liquid Capacity--- ------------gals. El- �. ,. .,�, r (01 e,. - :^__Distance from neares#_building-, ------------------------------- ------------------ --=--------------------- --- Privy: Qistance:from nearest well ... ..�H.� E ...� --------------------------------------------------------- J ❑ Distance to nearest Iot:l3ne_' :�: _-- ---------------"---- -- -------- Privy: - - A r Remodeli ucl or repaEring (describe]:___ :-- - } .._ - ------- -------------- -------------' :---- -;----- - ------- , s � A - r - - ------------------------------------------------------------- -•--- - -- ----- -- - -- --•--- ----•--- ------ ----- = w _ r_ ie i .. i ------- ------------• -------------•-------------=------------ -------------------:-------------------...-------- : - - ------------ ----- ---------- - 4 �-- r-,-- i4.. t I hereby certify+hat Ihave-prepared thisppli tion antha+ the work will.6e done in accordance.with San Joaquin County ordinanceS�,State law nd r_ul regula+ n o he Sarr44 oaqum La I Health District. rf o'4 i Signed) `E ( w d/or Contractor) P { 9 ] 4 , _ • --- -{Title) =----------------- SY• = _: - ------------- - 1 (Plot lan,.sf o lot, ation of.sys+em--in relation to wells, buildings, a+c.; can be placAed on reverse de]. -j - - r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ ----------------------------- ------ DATE--------- y ----------- ^- :. REVIEWED BY . ------ DATE - -=------ K ----------- -- BUILDING PERMIT ISSUED------------------------ F ----------- ' ------------- ----------- Alterations -------- - DA Alterations and/or.recom ' ;dations: P - = - , , -TH-=-=---------- ------ - -t-.._' : ------- -------- l - = I` -------------- ----- -------- ---- ------=----- --- ------- -------------------------------------------------------------------- ------ - -- ------ ---------------- r _ = ----------- --- O_W_Ni J=Jr S ��- �►!7.------ --"- WA_5------I/Vs F6 L".�- 1 .=> �f_ ,1�. n19 lis No vJ F0 N !a1l A!6- 5 `T/6 FPrGTa I FINAL INSPECTION-BY:.=� __ .r . .. .._- - - - Date------ ------------------------=-------=--='_=- -----------_---------- ------- SAN�OAQUI LOCAL HEALTH DISTRICT 7-1 _ 130 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 , Revised 1-57 F,P.CO. '�