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APPLI CATION FOR SANITATION PERMIT " PermitNo:r..-_-=_'2+,_a f (Complete in Duplicate) Date lssuedl-_. Application is her made e.San Joaquin Local He alth.Dm•+,istrict for a perto construct ani install the work herei d scribed. This application is made in compliAcee with County OrdinaKce l5lo,,,S. JOB A DRESS AND C,, ION:_.------ Owner's - t Name- ---------------- - d Addre one P 'T -_ _ _ - Contrator's Name--------------------- - ,•.F ..,�...._ :._----------------------•-------.-----•`----•------•------------=------- -----�`'•-;- t p _ _ Installation will "s_eFve• e`sidence A artme f House ❑ Commercial # "Phone---_ lumber ofliving uns: Number of bedrooms _-- ❑� Trade Court ❑ Mofel ❑ r, _ Number of bath`s .-. Lot size!�/ ❑ Wafer upplys- Pub€ic s stem 4 Y �❑ Community system ❑ Privat 'D;'� % 4. n �. i .. .E �` • f ter Table �ft Charac'er of`soil to a depth of f feef: Sand Gravel ❑ San Loam., ' a Y ,�,[] Clay oam ❑ G_la.y, AdobHa d � '' r Previou pplication-Made Yes.g.,,J�o �� p ❑ - ..,, ..�„R ew Construction: e No ❑ TYPE OF�iNSTALLATIOIV AND SPECIFIC TIONS -4 _. "' r #_ ��•;�__ (No septic fanlc or cesspool permit+ed if public sewer is,avai abiewvi m200•feef.) C / 1 S Septic Tank: Distance from nearest we --0-.--Distance from fou dati�n-_ * - �� Mated- --- _ W1,NO- of compartments-.-. _. Si _ -� -p - quepfih _-�f _Disposal Field: Distance from nearest well-_- Capacity -_.-Distance from fo�ndation __ /11� Distance to nearest lot line-- Number --------------- of lines-------------- ---------------------Length of each lin ------- ---- ' - -------.Width of french.----- yp��or filter r 1 ia -----------------`----De th of filter r ge, 'al 16 Seepa e Pif: Dist�nceto ne res# well # j t length-------- = --- --- Y + Distance fr foun tion-- � stafice to nearest lo} line vj►+ fits:.- ining mate,ial r Cess ool: 1�.'" +,. ,`S •;� Ize: Diam ter-- - Depth f i p Distance from nearest well-------------- S --------------- • Distance from foundation._.-____ _-_ ❑ E Size: Diameter--------------------------------- t ------ Lj' ing material------------------------------------- Privy:. --------------------- - ------------ Depth - --------------------------------------------- uid Capacity-,-------------------- -----gals. Privy:. � Distance from nearest yell----------------------------- � _--_--__Distance from near uildin ❑ Distance to a es "-online:-----___-- a g-- ---------------------- -t-- emodeling and/or repairing (descr.ihe)---------------------- --------------- ------------_ -_ - t ---•--•------------------------- -----•----------•-------------------------------------------- ---- ---------------- -- y. -------•----------•-------•--•---•-----------•--------------------------- ---•-----------fr� -------- ---------------------------------- t - -------------------•------- rt_ I hereby certify that I hate prepared this application and fhaf the work will be done in acco dl ordinances, State la , nd rules a d gulations San Joaquin Local Health District. ince with San Joaquin County (Signed)-------------- --- - -- - - ----- - BY: ----orf nen ra { w an Co + ctorJ r ---------• (Title)1--------------------- -- _____ Plot plan, showing size of, location of s stem in relafion to wells, buildings, etc., can be I } PI on reverse side), FOR PARTMENT USE ONLY APPLICATION ACCEPTED B _ __ r REVIEWED BY- r ---------- �---------•------- --------------- ATE � ----`� BUILDING PERMIT ISSUED--- = ATE - ----------------- - ------------------------- Alterations and/or recommen ' ATE--------- --------- ----•----•-- ----•----------•--•---------------•-------------------- --------------- , . -----• ------------------- --- ---------- ----------------------------------------- ---------------------------------- ------ ------ --------------------------- - ------ T --------------- _- I FINAL INSPECTION BY_____________ f � � g Date_.----- - - ----- --- `°'--- -- ---- ---------- ------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT V 130 South American Street 30D West Oak Street 132 Sycamore Street 814 North "C" Street i Stockton, California • A, Lodi, California .b. Manteca, California Tracy, California + ES-9-2M 10-52 Revised W-2100