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APPLICATION FOR SANITATION PERMIT Permit No. (t(gjl�yN (Complete in Duplicate) `}" 1 Date Issued - l cr3—� n� -1� 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. JI-c- JOoZ-1--ea 'S' 7- , Joos_ - - - / JOB ADDRESS AND LOCATION__......- __ -O fZ�e10----- ..-d ._/ �jr J �/ �G /` j( Owner's Name__. / ..,�.�.!�:r._.'��7s--cam✓ .... .. � ............ Phone............. ...................... Contractor's Name............... ` Installation will serve: Residence ❑ Apartment House [] Commercial ❑ Trailer Court [3 Motel ❑ Other ❑ Number of living units: --�_- Number of bedrooms _ Number of baths ..__� Losi -- ------- J,l�r I Water Supply: Public system ❑ Community system ❑ Private R--__D'epth to Water Table ft,:�plf I Character of soil to a depth of 3 feet: Sand 0-,Gravel ❑ Sandy Loam ❑ Clay Loam Z-<Ja y ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ( New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: """' (No septic tank or cesspool permitted H p ic�ewer is available within 200 feet.) Septic T Distance from nearest wail- - d-.-----Distance from foundation... Q__.-•-..Materia: - &-.6 O No. of compartments__.... ....'Y .Size. ,��a... ._Liquid depth..- .....capacity -•• I'll.----- Dispcsal Field: Datance from nearest well -.D:sta� room roundation i Q� - f.d�.....Disttsnce to nearest lot line__._�Q..-• � Number of lines -_--_ � ' Length of each line__.- ._ Width of french_-rt744��. - r Type or filter material... _ Depth of ril � if -------..._ Tofal length..._-7-,s.--- -J"-- --------------- G Seepage .it: Distance to nesresl well_..- -£�-�-_-Distance from foundationQ + - __....___.. Distance to nearest lot line.��_•_ a' Number of pits.....I-------- .___Lining material.,••- - Size: Diameter.- �/ / �• - Depth 0 - Cesspool: Distance Brom nearest well.................Distance fro ounciatio�._.--..__.... Lining material.........._____ ❑ Size: D amp:er.- ........................ .Depth__..--•---- ........... ........... -- -----Liquid CapacitY -----..... ......_.____.gals. � Privy: Distance from: nenrest well......... _-------__- __,_,.Distance from nearest huildin Distance to nearest lot line_______ _______________ --------------- ---------- Rnmadciing and/or repairing fdescrive):.--.__....______ - ------•--------- - -------------- - ------- --•--.--- - I hereby er+i that eve pre a d this application and + the work will done in accordance with San Joaquin Counfy ordinances, Sf to ews, an :rules an gulations of the San o uin Lo al Hea District. .o (Signed)......... -----... canes-aa Contractors .... .. -_.._. By:...... ........------------..--_.--------- ------....-.--- ` - {Title). Pot plan, showing size of lot, location of system in relation wells, buildings, etc., an be aced on reverse side). FOR DE TMENT USE ONLY REVIEWED BY..ACCI PTSD BY----------- - ..... -1 - DATE... APPLICATION _ !.._.. `.---- ....... ........Jnr`:..- •.......`_. - - - A - DATE...... -•- t•..--.�'.��_�--.. BUILDING PERMIT ISSUED............. f .... ....�..... _ - DATE......... vV ..... ti..� Alterations and/or recommendations:.................in. .. .--- :::� - =:/?.. :^: -----------•.............................................---------------------- i ..... .........................................--- FINAL INSPECTION BY:...... .._r. ............ Date �.-...�.. .-.5.7.. -... ................•--•-•---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North •'C" Street Stockton, California Lodi, California Manteca, California Traey, California ES-9-2M , Revisoa 1-57 F.P.CO.