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- IFAPPLICATION FOR SANITATION PERMIT Permit No. J a (Complete in Duplicate) � p Data Issued Applica4ion 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 Or 'nanco No. 549. JOB ADDRESS A OCATI f -------------------;�--------- A -- ------ - - Owner's Name---- ---- - ---- -• - ----1 --- -------- ---------------------------- - -------------------------=---------- Phone.-�,� .. Address------- ` ?3---- ---- -- ContrContractor's actor's Name F' �! - -' ----'------------------------------------------•------- ------------ Phone------- __`-----.�_-___�a_,,f Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _l____ Number of bedrooms_ Number of baths /.... Lot size Q / Q-----------__-_-_- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table,��ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob� Hardpan ❑ Previous Application Made: Yes ❑ I NoX- New Construction: Yes� No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 1 p4a�aFi,':I';I�: Distance from nearest well-------------____Distance from foundation___-________.._.__-Material________________-_________._________.__--_____. p ------Liquid depth--------------------------Capacity----------------------- No, of tom artments--------------------------Size----------------____-- � DispDistance from nearest well________________Distance from foundation--------------------Distance to nearest lot line____--_________ Number of lines goleaea Width of trench + Type of filter material------------------------- ilter mat ial--- ------------------Total length_-=-=_-�----------------------------------- Seepage it: Distance to nearest well�L-t7-_----- rom fo dation__ __ _...:___Distance to nearest lot line:__�____.---Linin mr �Number of pits.----�---_---- g _u-_�_ -__-Size: iameter--- .��.�--------.Depth--------- -Cesspool: Distance from nearest well_________________ rom foundatio ________- _:::Lining material__.__--.____-_______.___ --___Size: Diameter----------------- __----- ________ ___.__Li uid Ca aci#� --------- -- - ------- -- --- - -- q P Y----------------------------gals. Privy: Distance from nearest well------------------------------ -----------------Distance from nearest building----------------------------------------- ❑ Distance to nearest lot line----------------------------------- ----------- Remodeling and/or repairing (describe):___.__- _ L� ---- ______{_______________________________________________________________________________________________________________________________________________________________ ..______________________________________________________________-_____._______.______________-.________________________________-____-__-________________________________._________-___-_-_.__.______________________--_.-__-__ , I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County re ordinances, State laws, and rules and ulations of the San Joaquin Local Health District. (Signed)---- A/�ee-t� {Ownr. nd/or Contract ip. By: --------- ---- ffr. s - {Title) t �" -_------------------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be ed on revers de). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- +-- --- -- ----------------------------------------------------•--------------------- DATE- R ---------------------- ------------------------- REVIEWED BY---------------------------- Y----- ---------------------- --- -- ----------------------------------------------------------------------- ------ DATE--- � BUILDINGPERMIT ISSUED--------- ------------------------------------------------------------------------------------ DATE------QtN-------•---- ----------------------------------- Alterations and/or recommendations:- -------------------------------------------------------------------------••--------- � ----- •-•------------------------------------------------ --------------------------------------------------- --------------------------------•------------- ----------------------•---------------------------- I------- -----------------------------------------_-----------------------------------------------------------------------------------•-------------------------- ----------------------------------------- ----------------------------------------------------------- ---- ------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------- 1 ---------------------------------- - y - FfNAL INSPECTION BY: Date------------------ -- 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--2M ; Revised W-2100