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APPLICATION FOR SANITATION,PERMIT Permit No. (Complete in Duplicate) ` /4�,� � Date Issued Application is hereby madeo 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. JOB ADDRESS AND LOCATION - - ------------------------- ------------------------- F Owner's Name---- � - { Address . � e- ----------------------------------- .. �i ---- ----- --- --- --- actork Name- �_- Phone./0�4h Cont� -. 1 Insfall'ation will;serve: Residence. artment House ❑ Commercial Trailer Court ❑ Motel ] e ❑ f' (s Number of baths _5�-. Lot size - � `,��------------------------------ Number of livingunits: _- Number of bedroom M4 f 1 -" Water Supply: Public system - Community system ❑ Private ❑ Depth to WateyTablC1ft. Character of soil to'e depth of 3 feet: ,Sand ❑ Gravel ❑ Sandy Loam❑�"Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No ❑] FHA/VA: Yes ❑ No�' TYPEOF INSTALLATION AND SPECIFICATIONS: �(No!septic-tank-o'V-caspool permitted,&public sewer is available within 200 feet.) Septic Tank: Distance from nearest well :TlDistanc from foundation.-�1. &M2ri I_-- _p-_-__ ?----____- �{ No of compartments-_ -_-__--Size--�___�' .---- _-- Liquid depth--�_- ---.� -- Capacity.-_-- dc�J__-s- � I -_-Distance to nearest lot line__-�� Disposal Field: =Distance from nearest well—,,, ''_____.Distance from foundation ___-- ti - O-__-- _--_ Width of trench____,.--------------- . umber of lines-------- -------------- -Length of each line-------- _ �i '= Q (T�y_pkq of filter material- --.-_ iDe th of filter material__- --.d? Total length-!---_- Z ------------------------- Distance ----- "------� p f Seepage Pit: ,�i'stance to nearest wall-, -___.Distance from ndation�l-- Dista ice�o n crest lot umber of pifs-.--�--------------Lining material�f __----Size: Diameter ---fir---D pfh---.- _----�7------- Cesspool: Distance from nearest well-----------------DiifEn—ce from foundation----______------_-Lining material------_-_-----_____----------.__----_. ❑ Sze: Diameter------------------ ------------------Depth----------------------------------------------- --Liquid Capacity----------------------------gal -- Privy: Distance from nearest well------------------------------------------------Distance from nearest building--------_--_-- _---------_-____--_--_--- ❑ Distance to nearest lot line--- ----------------------------------------------------------------- ------------------------------------------------------------ I } Remodeling and/or repairing (describe r r -- '- -- -------------------- --•--------------------•--•-------------------•--I--------- --•--------------------------------------- --------------------------------------------------------- ------------------ -------- 11 --------------------------------------------------:---- c,.�---------------•--•-----I•- _-----------------------'---------- # I hereby certify that I have prepared this application nd that the work will be done in accordance with San Joaquin County ! ordinances, State laws,� d rules an egulations f the n Jo in Local Health District. 1 ----- -Owner a r Contractorl (Signed)--- -_- -- -- - - - - - � � - ------------------ - -------------------- ----- Tif e By: I y ) (Plot plan, showing size f lot, loca ion of system i relation to wells, buildings, etc., can be pl ed on rev se s' — FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY "%1 -.Q°. I---------------------------- DATE -% * � f----�---------- -- REVIEWEDBY-------------------I--------------_------------------------------- --------- -----------_------------------------- ----- DATE--------------------'-.-------------------------- ------ ( BUILDING PERMIT ISSUEb------------------------- ----------•1----------- -•-----•----------------- --------------- ---------.DATE------------------- ----------------------------------- IAlterations and/or recommendations---------=----------- -------------------------A----------------------- ------- ----------,-----------------I -----••--------------- / n f/ } M _t- ------d ----- i ', ".`.. -------- -- - --------------------- ' ------ -.;-- =------ -- --------------- ------------------ -- - ' --------------------t � - t I �. fes-- �� l Jr~S I FINAL INSPECTION BY -, -;--=---- - Date------- -------- -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Soo West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revises 1.57 f.P.CQ.