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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued ---- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install thg 4work rein described. This application is made in compliance with County OrdjnancQ No. 549. . . ........ JOB ADDRESS ANDLOCTIONI .0 -- --- - ----- -- -- ------ ..... .............. ... ........ ..................... Owner's Name......-:... 2* �.� - --- ---------------------- ---------------------------------------------------• Phone.,*.__4`)_ Address... ........... ...... -------- .----------•-------•-•-•--------•----......•.............................. Contractor's Name... 7, 4�j ',...... ......................... Phone,,* 79 Installation will serve: Residence �arfmenf House [] Commercial El Trailer Court [:] M ot%1Other ❑ ,P Number of living units: Number of bedrooms ...1!�'Number of baths _/_ Lot size ----- ------7-7---------- ---------------- Water Supply: Public system El Community system E] Private W5 .� fh to Wafer Table ft. e I Hardpan Character of soil to a depth of 3 fe t: Sand 0 .Gravel [] Sandy Loam 0 Clay Loam [] Clay ❑ Adobe 13�,ii <a El Previous Application Mad®: .1 14 le, Yes [D' No [R—9�w�Co�sfruction: Yes [] No UK FHA/VA; Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS:' f;-public sewer kis"availabIL-.within 200 feet.) (No septic tank or'cesspoof permitted i Septic Tank-. Distance c'e from'foutn�-fion......4©.....Material.-_Distance ---- No. of corripa�tment ......2--- 4�4 .'kiqu ......... . s ...........__Sjze_Z% e- ---- id cle.o.th.... . Capacity_- ....... x -IAO* I Distance from nearest Di'sfancYo-m3"' -.or....... f nearest lot line.-gZ9.0.000 Dktosal F*trcT-- a'eif foundation.... Distance 6" Number of lines -------Length of ea"ch line------ -. _......Widthof trench.... ......... Je,14_..-_Depfh_'of fi]Ter�im;aferial...... ....Total lengt�.......-Al_o---------------------- oQilferlrn Seepage Pit: Distance to nearest well_/1740.. ---Dist,n,ern oundafio,,/.0.__"......Diltance to nearest lot line. Number:of pits..!"-./.... .. ... ...Lining material dt� t Diameter..... 3!......Depth.._02__,FZ---- Cesspool: Distance from nearest foundation................... Lining material.__-... __.._..----........... 171 Size: Diameter.. ............ LiqCapacity.._.._.._._..:...... .................................................. uid Privy: r --- ng_�.......................... Distance from'in�a est well.... ...... ........Distance from nearest buildi El Distance to nearest lot I - ---------------------- ------------ ------------------------------------------------------------------- ------------ Remodelp and/or repairing (descr;661):_ .... ------- ... . ....... ............ ---------- --- ------------- ........ I................... --------- ............ ---- -----------1-............ -------.... .. .. ........ ------- .............. .......... ....... ................................................ ............................................. ......................... .... ----------------------------.... - ----- I ----------- ........:!.... .............................`---•---••--•---_------- ............................................... I hereby certify that 1-have prepared this application and that the work will be done in accordan'ce with San Joaquin County ordinances. State laws, and rules and regulations of'the San Joa*uin Local Health District. t - (Signed V 4_1 ---------- .. ... .... ...................... ontractor) By................... -••-----.-..--•-----•-----.-•-----•- ----------------------------------------------------------- ...........!7.. ........(Title).............. --------------------------------------------- (Plot plan, showing size of lot, location of system in relation wells, 6 ild s,. c.. can 69 placed on reverse side). FOR DEPARTMENT USE ONLY wellis, 6u,1 ng APPLICATION ACCEPTED BY--- --- ------------------------- ------ ----------*......... ................ DATE----------......4.7 REVIEWED BY. ---- ----------- -----------------'--•------------- - ----- .... ................................................. DATE....... .......... ... BUILDING PERMIT ISSUED-------------- ..... ------------------- -- --------------=—••••-••••---..._......••..........-... - --------.. ......... --------------- Alferations and/or.recommendaf ions:........ ---------...................................................................... .. ................................................ .............................. --------------------------....................... ----------------------- ................. I ......................................................................................... .0 .................................................................I................... ---_-----------...............................I....................................T------- ........I.................. ....................._......................................... .......................................................................................................................... ......... ...................I........- . i I I .........................................- -------- -----•--•--•-------------•------ --------------------- ..................-- ----------------- ............................ FINAL INSPECTION'-BY:._......01r -- --__ • Date I ------- ------- ----------------- ............................................ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South Amorican-Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1.57 F.P.CO.