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3� f ✓ APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) 3 Date Issued --- A __ Application is hereby made to the San Joaquin Local Health District for a permit to construct and instal the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND L0CATION-----,f---2-2_ -----40 k -------------- ----------------------- = I R Owner's Name--- " ------ Phone----------------------------• ----- I Address. ------ -------------- --- ------------ ---�=-----------------------------------------------...__... Contractor's Name--------------- I� Phone.. ----- IM ,+� Installation will serve: Residence [p�partment House ❑ Commercial ❑ Trailer:Court ❑ Motel ❑ Other ❑ /� 4 Number of living units�`._`1___ Number of bedrooms __,Iw Number of baths __, - Lot size _ _ ./� ------------------------------ Water Supply: Public system' ommuriify system ❑ Private ❑ Depth toWa+tler Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clayroam [I Clay El Adobe r ardpan ❑ Previous Application Made: !es F1 No [��ew Construction: Yes ❑ No [ FHA/VA: Yes E] No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'ces pool permitted if public sewer is available within 200 feet.) Septic Ta Distance.from nearest well_________________Distance from foundation___---_________-_-.Material___________-____________________-__--._-_____- 71 � No. of compartments--- -------- - ---- -----Size-----------------------•----:---Liqui�dei?th--------------------------Capacity---------------------- I % Disposal Field: Distance from nearest well____-_Distance from foundat.io`n _J40_--------Distance to nearest lot line______---_. Number of cines-------�f _�-s_______---Length of each line---- r �� h i Width of trench---.-_. __ Type of filter material --tel-Depth of Cter mater al___� __-___-_;_Total length---------- r____________________ $eepa Pit: istance to nearest well__:'��`'___ __Distance fr m ,fou dation __� ____.Distancg to nearest lot line____ __ :� t+�y ,4,; ��pvilumber i f pits.----/--------------Lining m}fit`efrial_` _ � ._°Sizereter__,.� ---------.Depth_---- -- r------- Cesspool: T!r Distancefrom nearest well-----------------Distance from ,foundation-_.___--______-_- Lining material_--________________._------_______--_ V ❑ Size: Diameter Depth x:_-, - Liquid Capacity gals. Privy: Distance from nearest well-----.- ----------------------------------------_Distance from nearest building______---___________-____-___._--_____. ❑ Distance.to nearest lot line- ---- - - -- ---- = '------ ••- Remode$ing and/or repairing (describe)----------------- `4� ------------------------------------------------ 1 1I` I----------------- ---•---------------------- ------- �: - ---------------------------------------- ----- ------------------------------------- ------ ------------I------------------------------------------------ - -- I" 1 hereby certify that I have prepared this a} plicafion and that the work will be done in accordance with San Joaquin County ordinances, State laws, and `ules and regulationsoft e San Joaquin Local Health District. 41 s ----(Q�or Contractor) (Signed)--------------------------------- - -------- -- - -- - -- - --------------- ----- ------------ I = ------------ ----a.................(Title)------ "„a------------------------ BY� �� (Plot plan, showing size of lot, locafion of syste relation to wells, buildings, etc., can be placed'on reverse side). FOR DEPARTMENT USE ONLY f APPLICATION ACCEPTED �BY r R s - DATE ZJ_-31` 9 REVIEWEDBY---------------------------------- - ------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUE{)11------------------------ ----------------------------------•----------------------------------------- DATE---------------------•--------------------------------------- Alterationsand/or ecommendations:--------------------- ------------------------------------------------------------------------------------------------------------------------------------------ -------------- ••-- 1 T IT N.--------�'5-------- _----_Tim_d I----------------------------------------------------------------------------------------------•---- ---------------------------------------.-.-.-.-.-.---.--�-.i.1'-,---.-.--. ---.--------.---.---.---.--.---.--.---.---.--.-.-.-. ------------------------------------------------------- ------------------------------------------ -----------------•------------------------------------------ ---------- ---- ------- ---- ---------------------------------------------- :I ------ - ---- -------------------------------------------------- ------------------------------------- ' FINAL INSPECTION BY:._- - _______ ______ ______ Date-------_1__----`------5 •------------------------------------------ SAN JOAQUIN LO ,;HEALTH DISTRICT 130 South American 5treet-l 300 Wes+ Oak 5+roe{ 132 Sycamore,Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California r ES-9-2M , Revised t-57i F.P.CO.