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APPLIc-, TION FOR SANITATION PERMIT .-o Permit No. _"--.- ----•---• ---- (Complete in Duplicate) Da#e Issued . ��--5-y Applica`ion 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. , / - .. .. -•------------------------------- ION-1-1 JOB ADDRESS AND LOCAT _-- -- -------•-•- one Owners Name,.__ __ _ ) ► �: Address - ---------------------------------------------------•---------•= r Contractors Name----�- --• -- ----•--------------------------- --------------.- r ( Phon -- =+ F3 I f` Commercials❑ Trailer Installation will serve: `Residence [Apartment House ❑ / Court ❑" Motel El Other C1 Number of 1 baths -f---- Lot,size Number of living units: f_ Number of bedrooms _ } Water Supply: Pubiiclsystem mmunity system ❑ - Private ❑ D'epth to Water Table's Charecfer of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [I Clay Loam❑ Clay C] Adobedpan ❑ Previous Application Made: Yes ❑ No 4---Wew Construction: Yes.[1, No 14 TYPE OF INSTALLATION AND SPECIFICATIONS: ° (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic:Tank: Distance from nearest we11,0*_-.. _- 4_-Distance from foundation_ %-6__f_-----Material-------------------------------------------------- -r ---Size . det - j - -----,_ ----- Capacity---•rS-�---- No. of compartments------- -------- _ �, F pis o al Field: Distance from nearest well__."_____._____Distance from foundation_______.__:___.__.-Distance to nearest lot line------p - Nu"rriber of lines-----'--------==-----=-----------Length of each line.,--------------------------Width of)trench----------------------------------- El --------------------- ----------- ❑{ p s -------- -F---- 9� ------------------------------------------ Typ of filter material--------------------- --" ` a ' crest wells "y"� ----D scan effrotmrfoundation__ (� Distance to nearest lot line__ Q"r--- _ ,.� Seepage Pit: D'+itance to ne ;�c, . -r r- .Ue. #h_"- r Number of pits-----. - Lining material.:�t�c�_.-sae. Diameter._- P �--------- -------- ------ - --- '� t CesspooLD #a ce.fioearest well________________Distance from foundation.__. -_______._-_..Lining material______.__"____- _________,________ Size: Diameter Depth ------------ ----------- ---=- Liquid Capacity_._.._ gals. k ` -�..r - Distance from nearest building------------------------------- ------ Privy:r Distance from.nearest well------------------------ _ e `._------.'._"-_-- --- ----- •y ' _ -------------------------------"----------- ❑ `Distance'to nearest.lot i�ne_____°""'--- - ------ - - ° t ---- Remodeling as repairing (de.`cri e --------------------- --F-; I I ------------------••---;------•---I-•----•---7----- •..._. f ---•-------------------------------------------- ------------------------------------------•------------------------ ----------------------- ---------- 3--------- r t . i. "'". --------------- ........... .-- -----•- --- •------•- ---------•----•-----•----------------------•------------------------'---.._._..__..------.. --_..------••----i_ ----------------------------------------------------------- -----------------------------------•_---------- I hereby certify that"nd'r I-leave.prepared this application and that the work will be done in accordance with San Joaquin County ` q ordinances,J� laand regulations of the San Joaquin Local Health District. i (Signed) --------------- Contractor) ._.-r ---(Title} f n ra (Plot plan. showing size of lot, location.of system in relation to wells, buildings, etc., can be placed on reverse side). i y FOR DEPARTMENT USE ONLY r , APPLICATION ACCEPTED BY-.!!........... ;.-- ----- DATE------- �----------------- -------------=---------- 1 REVIEWED BY------ -'----=-------- --- -------- F DATE------- --•--- _ BUILDING PERMIT ISSUED___-_----- ----- ------------------------------------- ----- DATE qca------------------------ ------••----- ----------------- --------------------------- Alterafions and/or recommendations:------- _ F --------------------------------------------------------- ---------------------- -----------------=---------••----------------------------- -- --- ---------- , -----------•-------------- ------ ------- - ---••--------------- ---- -----•---------- -------- d -------------------- ---------- ' Date__.::/__Z. :.: = ------ FINAL' INSPECTION BY:. - _------------------------ -- SAN JOAQUIN LOCAL HEALTH DISTRICT Soo West Oak street 132 Sycamore Street 814 North "C° Street l30 South American Street Trac California Stockton, California Lodi, California Manteca, California y FS-4-2M Revised W-2100