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`�4 y Permit No. 0�-- -- 1 APPLICATION FOR SANITATION PERMIT / (Complete in Duplicate) Date issued _?��_'3:7- I � � Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein des c ribed. This application is made in compliance with County Ordinance No. 549. ' f ----•----- —------------ JOB -�------------------ JOB ADDRESS AND4LATION________ _AGO --------r- Y--- Phone Owner's Name --- ----- ��t_��.�-1111-- - f _ 1111-1111---•1111------•11 11---••---------1111-- Address-__ �er�,�.-.....__.r- .. ------------ ------•-----------•------------ 1------------ - E'� '� Phone. Contractor's Name________________________ � .--�----- ---- Installation will serve: Residence{ Apartment Hou ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .f___ Number of bedrooms` -- Number of baths I---__-- Lot size ___ ----------------------- - Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table.... f Character of soil to a depth of 3 feet: . Sand ❑ Gravel C1Sandy Loam El Clay Loam ❑ Clay E] AdobA Hardpan ❑ Previous Application Made: Yes ) No New Construction: Yes No ❑ T s TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ' Septic Tank: Distance from nearest well-�xsA,1'--Distance fronq foundation__-/.�_..-1111-Material -- ------ -__��_•___Liquid depth_ __ _ --_--_--Capacity---fG�------- X No. of compartments-____-�_-------------size, r r Disposal Field: Distance from nearest well-.Distance from foundation_- ___,-.-----Distance to nearest lot line____�_.____ O Number of lines---------1______--- -- -•-------Length of each line--------- {J----------Width of trench-1111-- ------•-------------- �� Type of filter material_T-____--`Depth of filter material___/ -___--___._Total length-- _____- _-_-.1111•---_-�_ 1� Q _ Dist nce to nearest lot line_�___�___ �U Seepage Pit: Distance to nearest well,jl�r- - _____Distance fr m four?dation____ ___ _______. �' Number of its_- g �'-- Size:Diameter---- -------------Depth------- _5 p �-:- -- ---Linin material__ -� - - -- ----•-----1111-- Cesspool: Distance from nearest weld-------------_---Distance from foundation----___________ lining material__-------______-____---____________-- ----Depth----------------------------------------------------Liquid Capacity - gals. ❑ Size: Diameter,- 1111 111111 11--1111-- 1111- Privy: Distance from nearest well-----------------_-._1111---------------------- -Distance from nearest building_____---;--__________-_---------------- ❑ `._ �. Distance to nearest lot line------------------------------------------------ ---------------- ------ _ Remodeling and/or repairing (describe):----------- --------------•-------------------------=--=---------------•-----•-------•-----------------•--------------- -----•1111•-------------------- ----------------------- l - ------------ --------- --- - ----------- ------- ---------------------------------------------------------------•-------------------•--------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State ws, and rules and regulations of the San Joaquin Local Health District. _ ------------ " -(Owner and/or Contractor) (Signed)_ . -1111-- �.��-.-----�-• � -- --1111-- --�-1111-- ------111111 11-;----------------1111-- ---1111-- - (Title}� ,., ---- ----- -- 1=111-1111-- $ :------------------ = y. k - , i (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be platted on reverse side). FOR DEPARTMENT USE ONLY l APPLICATION ACCEPTED BY -- --1111-- - t-1 ` -------------------•------------- QATE �REVIEWED BY---------------------------------- ------- ------- ---- - -- QATE-------------------------------------------------- --------- � ---•---- DATE------1111-•------------------------------------------1111-- BUILDING-PERMIT ISSUED--------------•-------------------------------------------------------------- Alterations and/or recommendations:-------------------------------- ---------------- t ----•••--•-••-• --------------1•_----------- - ---•1111---111111 11-111Orb --•-1111-- - ---1111-- - --- ---•--------•-------------•----------------------------- -----•-------- -1111----------1111-- -------1111-- ---r FINAL INSPECTION BY: ---------- ,� Date_-- ----------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street -814 North "C' Street _ 130 South American Street Trac California Stockton, California Lodi, California Manteca, California y ES-9-2M Revised W-2100 - _