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APPLICATION FOR SANITATION 4 PERMIT yPerm+?NO. . (Complete in Duplicate) E �f Date Issued /--d 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 compliande with County Ordinance No. 549. JOB ADDRESS AND LOCATION__ - _:___ _ __ --------------------------------------------------------------------------- r Owner's Name-------•C--r---- ------------------------------------------------------------- -- Phone �r 9 I. Address-----------•- ------------ -------------------------------------- ` = ------------------------------------------ Contractor's Name---------------------- -. ` -----/ Phone_-----------------------•-------- Installation will serve: Residence gio5artment House ❑ Commercial ❑ Trailer 'Court ❑/Motel ❑ Other ❑ Number of living units: __/__ Number of bedrooms -%Y_- Number of baths __ZLot size��&__. � � Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table*,&t_ Character of soil to a depth of 3 fee+: Sand ❑ If Gravel ❑ Sandy Loam ❑ Clay Loam [] Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No .(4"New Construction: Yes ❑ No FHA/VA: Yes ❑ No R�-- TYPE OF INSTALLATION AND.SPECIFICATIONS: r (No septic tank or cesspool permitted if public sewer is available within 200 feet.)J `Ir *JY,,4`1I tic Tan DistancE;,Jroom nearest well-----------------Distance from foundation____` _�--------Material________________________________________________ � No. of com artments__________________________Size-_-________ __Liquid de th------------ ----------------------- X { - .�. q P. .� apacity Di�sp s I Field: �istanace from nearest well-__! _ _-.._Distance from foundation---�r_4____ PA to arest lot line__w4 . -_- /41l► ;`*4 f/f Number of lines'_ __ __ _______ ength of each line_____J.4��-Widfh of trench___,_ !r ------------------ Type of filter material_ _ Q,a `Depth of filter material____ _ __________Total length_______s.��"'tle�'s�Ne-_______-- I i pQ/" Number ofrPit -:-l---- gJmaDteraal_e1�s� f Site. �e,_ Dista�Fe to to in�e�',� I Seepa e Pit: Distance to nearest well- 'r --------- Cesspool: Distance from nearest well-----------------Distance from foundationq----------------Lining material----------------------------- ❑ Size: Diameter ----------Depth--------------------------------k------------------Liquid Capacity----------------------- gals. ` Privy: Distance from nearest wefl---_____________________________________-___._Distance from nearest building_____---_-----------_______________-__ r Distance to nearest lot line_______'- .---___-_______.--._ -- Remodeling and/or repairing (describe): �/ i ------------------------------------------------------------- _ __ F_____-__-__________________ ..------_ i I ll. I 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, nd rules and gulations of the San Joaquin Local Health District. (Signed)---------- ---------------I-------- Contractor) By: - --"' -------------------(Title) 'P1 �!`�..rt► ----------- (Plot plan, showing size of lot, location of s in.relation to wells, buildings, etc., can be placed on reverse side). r 3 ( FOR_DEPARTMENTXSE ONL-Y,..•....•�-��.Ij APPLICATION ACCEPTED BY---- --'----------------------------------------------------------------- DATE--- _r r J REVIEWEDBY---------------------------------------------------------------------------------------------------------------------------- DATE--------------------------------------------------•-------- BUILDING PERMIT ISSUED---------------I-------------------------------------------------------------------------------------- DATE.------------ Alterations and/or recommendations: N°` -- ----- ' ----------- ------- ------------- -------------DxM------- ----------------------------- ----------------------------- ------------ - -------------------------------------------------------•-•----------------------------------------------------------------------------------- ---- •------------------------------------- - ---------------------------- ___________________________________•_---_-__-- _'------------___-_ _____ _____ _ _ _ 4 FINAL INSPECTION">3 V Date------ �� 7------•- { F SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American•Sfreef 300 Wei+ Oek Sfzee+; 1!?�Syca�moore-Sfree+ ai y 914 Norfh "C" S}ree+ S+ock+on, California Lodi, California Manteca,California {"' ♦ Tracy, California �h ES-9-2M Revises 1-57 F.P.CO_