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E?PtRES ONE YEAR ` APPI_ICATlCN FOR SANITATlt..wPERMIT Permit No_ j.._. _.. FROM DATE (Complete in Duplicate) 7 s Date Issued Appiication is hereby made to the San Joaquin Local Health District for a permit to construct and install the wort; herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCA TION ( G ---.-_ Owner's Name-------------.�.L1�11//-�---•---•---1- - - -- --- ------ ------------------------ --- hone Address ------------ ---- 4 �~� - Contractor's Name ---------•----- - ------------------------------ - ------------------------------------ Phone------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --1Number of bedrooms Water Supply: ------ umber of baths __--�__ Lot size _.___ _ - ---- ------- -- -------- Public system ❑ Community system [I Private --I�pth to Water Table �--ft. Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑, Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe E Hardpan ❑ Previous Application Made: Yes ❑ No [ New Construction: Yeso . . QFHA/VA: 'Yes ❑ No D+- TYPE OF INSTALLATION AND SPECIFICATIONS: [No septic tank or'cesspool permitted if public ser is available with 200 feet.] Septic ank: Distance from nearest well_r-_� i/1•�---Distance from foundation_ ___- / .- _ ��-------.Material- - ----Q.�_ �_ No. of compartments__________Size_ ��-1C -------_ -.Liquid depth __ t CepacitY-- Sf�r- _ ; Disposal .ield: Distance from nearest well__ __ -__---Distance from foundation.__. Sw �_�----.Distance to nearest loft line__ - Number of lines----- _______ T-------" I ength of each line -- 6-I I --wid+h of french--_._____�--/�7 Type of filfer material____,�QC/�Depth of filter materiaL___J--?-' -- i ----Total length--------�-��-----------------•- eepage Pit: Distance to nearest well _____ _-____Distance from foundation--------------------Distance to nearest lot line_-________._____ ❑ Number of pits----------------------Lining material` Size: Diameter Depth �. Cesspool: Distance from near'est:well_______________•_Distance from foundation_________________-.Lining material------------------------------ F1Size: Diameter------------------------- ---------*'Dept h. fir. ------ --------------------------- Liquid Capacity ------------------. gals. Privy: Distance from nearest well-------- y-------------------- --------- Distance from nearesf buildin ❑ 'Distance to nearest lot line-------------------------------- _ t ----- ------------ ___________________ � ' Remodeling and/or repairing (describe):------- ,fes .rb.J�.�' c ,yr_• (.f�l,�_ ------------- ---- _.+ --- • ------------------••------- •- ---- -- - I hereby certify that I have prepared this application and thaf,-the''w k will be done in accordance wi+h San Joaquin County ordinances, State laws, and rules nd regulations of the San Joaquin Local Health District. (Signed) � � - � ' _ ---[Ow . • _ _.M (Owner and/or Contractor) ly. ------ �--------------- .. (Title) o 1 (Plot plan, showing size of-lot, Iota+ion of system in relation to wells, buildings, etc., can be placed on reverse side). _ -FO DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------- --- --------- - ------------------------------------------------------------------ DATE-. ----- --- REVIEWED BY------------------------------- ------- ------- -- --------------•------------------------------------------ BUILDING PERMIT ISSUED---------------- --- -- DATE_;-------- -•- ------ DATE------------- - Alterations and/or recommendations:__-_----I._ -------------------------------------------- ------- - -----------��-- -- - --------------°---- ----------------- l----- -- ti .rte, e_. ----- ---------- ---- F tLt•-------- ---•-- lZ- --------- / l,-JL {i G�- Gins, FINAL INSPECTION BY------------ !�f - - - - -- ----- ---------------------- Dae.....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 �. � Tracy,,California ES-9-21x1 Revised 1.57 FRCO. —s