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APPLICATION FOR SANITATION PERMIT Permit No. ___1,- S......... T11 (Complete in Duplicate) R `I 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 Or ' ante No. 549. li JOB ADDRESS AND LOC ION .__ --- ______"-__ .tn-G_�-- _ Owner's .Name---- e-----------------------------•- Addresss'� ---•--•--------- -----•--------------------•----••-------------- Contractor's Name A �lC.- Phone -•------- Installation will.serve: Residence// Apartment House ❑ Commercial ❑' Trailer Court ❑ Motel E] Other El _!- Number of living units: ._I Number of bedrooms S y Number of baths --/--- Lot sizes� . /- Water Supply: Public system ❑'' Community system ❑ Privateepth to Water Tableft. Character of soil to a depth of 3 feet: Sand.❑ r}Gravei ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ ? Previous Application Made: Yes ❑ No ,<New Construction: Yes�No ❑ FHA/VA: Yes ❑ No [ Y TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted.if;public srewer is available within 200 feet.) ; i Septic T Distance from nearest wel _ :_=Distantom fo dation__ 4f.._____.Mate�iaJ_ _ _ No. of compartments__ - - -------Size- ---- - I�__"Liquid depth--- _-- T-------------Capacity_-- --r�� ` r` I, Dis osaI F" Id: Distance from neare we€i_ "__.(.Distance from foundation��____.--_-_.Distance to nearest t line-/-- p Number of lines---- Length of each line_-' �_�_____ Width of trench__ �� T e of filter material _ _ _.._"_ -Depth of filter material__"-_.-�_-__"_--Total length--/ Yp p �. See Distance to nearest well___'_ ::_----------Distance from foundation____________------- Distance to nearest lot line----------------- } - Number of pits------=---------------Lining material-----------------------Size: Diameter-----------------------.Depth-----------------------------_- esspool:`,"� Distance fromtne'arest well________________"Distance from foundation._._"---_._.-_--_--.Lining material".-_""..__-____________---__---.- ❑ '". Size: Diameter�---------------------------- ------:-Depth---------------------------------------------------Liquid Capacity--,.------------------------gals. } Privy: Distance from nearest well-------------------------------------------------Distance from,nearest building------------------------------------------ ❑ F Distance to 'nearest lot line-_------------------------__ f Remodeling and/or rep'airi (describe):__.___. _ � f--- _ - _______________________ - _. - -------------------------------------- -- ----"---•- ----•------------------ 11 -------- - --- - ----- --- ----- __ = - ----------------------------------------- -- -----` '. .. K I hereby certify that I have prepared this application and that the work will be done°in accordance with San Joaquin County ordinances, State laws, and rueandreguns of the San Joaquin Local Health District. (Signed) ----- -� ---- Contractor) By•------------------------------ - -- ----- ----------- ---- tle_ _ _ - [f�lot�plan, showig ize ofdm in`relation io w`ells; buildings, etc., can be pla ed on revers rde). T ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED SYR----- -------------------------- -------------------------------------------------------- DATE-,_— BY -------------------- ---•----------------------------------------------------------- DATE----5?------------------------------------------------- BUlLDWG PERMIT ISSUED ----------------------------------------------------------------------------------- DATE---- --------------------------------------------. Alterations and/or recommendations:------------------------------- -----------------------------------•---------------------------------- --------------------------------------------------------------------------------------------------------------- I -----------------------•------------------------------------------------------•----------------I--------------__-------------- --------------------------------------------------------------------------------------------- FINAL INSPECTION BY:-- " / = =-------------- Date--- ---------------------------------------•------- .� ._ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South+American Street }' 300 West Oak Street " 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California 1 Manteca, California Tracy, California p� ES-9-2M .Revised 1.57 F,RCO.