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APPLICATION FOR SANITATION PERMIT Permit No. p 9A (Complete in Duplicate] 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 Ordinance No. 549. JOBADDRESS AND LOCATION--------! �rb - --------------------------------------------------------------------------------- Owner's Name---•-_ ---- -------------------------------------- F Phone-----------•--------•---- -S---------- ----•------ ----------------- -------------------•-Address----------- - -4-3�_4--_... --- ------ L --Y` Contractor's Name----------- --- Installation Ji. will serve: Residence [4 Apart ent House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ Number of bedrooms _. __ Number of baths __ -_ Lot size __-___l/a_�k__r— ----------------------------- Water Supply: Public system ❑ Community system ❑ Private ® Depth to Water Table I ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe IN Hardpan ❑ Previous Application Made: Yes ❑ No [& New Construction: Yes Q No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation-------------------_Material-.______---_-_-___.____.______-_____________-_. ❑ No. of compartments--------------------------Size--------------------------------Liquid depth Capacity Disposal Field: Distance from nearest well f-__-Distance from foundation-lo....______..Distance to nearest lot line)®_*-_______- [� Number of lines------------�________________Length of each line---- �____rfe__---------Width of trench___.� _!___________________ Type of filter mate ria l - act---------Depth of filter material___.1V=- ---------Total length--------?d___________________________ 11 Seeragc�'Pi'I•: Distance to nearest well____!Qo--------____Distance from foundation__0!___---------Distance to nearest lot line---/A_-------- � © Number of pits--------!------------Lining mate ria l_-113Q_0h-------Size: Diameter----�,J�__7--------Depth-_._V`______/____________________ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- ❑ Size: Diameter------------------------ Depth - Liquid Capacity gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------_--________________-.____----- j] Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (clescribe):-o,--- ------ ----------------- _..,- ---i------------7=�------ -^t -m -- ---------------------------------------------------------- --------------------- ---------------------------------------------------------------------------------------------------------- - �, I hereby certify that I have prepared this application and that the work will be done in accordance with San Joag4tin�County ` ordinances, State laws, and rule and regulations of the San J aquin Local Health District. r Owner and/or Contractor (Signed)-------------- { ) $ ------------------------ ----------------- ------- -- ETitle] �� r�� y:----------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY---- ------ ---- --------------------- ---------------------------------------- DATE-------------------- ---------------- REVIEWED BY-------------------------------------------- -- -- - - --- ----- ----------- ----------------------------- DATE------------------- 1-- ----- ------------- BUILDINGPERMIT ISSUED----------------------- ----- ---------------=--------------------------------------------- ---- DATE------- Alterations and/or recommendations:----- ---------------------- --------------------------------------------------- -------------------------------------- --------- --------------------------------------------- --------------------•---------------•----•--------••-------------- ----------------------------------------------------------------------------------------•---•--------•-- ------------....----------------------- -------------•--------------------- --------------------.--------------------------------------------------------------------------------------------------------------- ---------------------------------------------------- --------------------------------------------------------------------- ------------------ FINAL INSPECTION BY------- - ---- ----------�_-�-- ' - - Date- -_-- 'a -- -------------- SAN JN LOC' L HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street pP'r Stockton, California Lodi, California Manteca, California Tracy, California ` E57.-9-2M Revised 1.57 F.P.CO- �..