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- q APPLICATION FOR SANITATION PERMIT Permit No. __ ------ �`�____ (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with Coun=ty Ordinance No. 549. JOB ADDRESS AND LOCATION-=-------f -� 1�------%T1----10-L-1 Owner's Name----------------------- ---------- - ------------------------ -------------- ----------------- Phone--------3-4f5&--I Address------------------ 1.7--------- -A`' ---------l0A-y--•-------------------------------------•-----------------------------------------------------------------•---•-•-•-------- Contractor's Name (0-0,1_ l �14_ 0,±1�T/2'` •------------•------- Phone----------- ------------------ x Installation will serve: Residence Q"'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ____ Number of bedrooms __;�/___.Number of baths Lot size ____ a__ ! !_____________________ Water Supply: Public system [Community system [], Private 0 Depth to Water Table Y'k,ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam 0 Clay E] Adobe[Hardpan-❑ Previous-Application Made: Yes ❑ No [/ New Construction: Yes No ❑ FHA/VA: Yes ❑ No TYPE.OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) O W0'0Z)` Septi ank: Distance from nearest-well__�l.1t__,___.Distance from foundation_---a-______-MateriaL__UAS 0,t �'•l.�_ _ [] opr + -Size --- ----�--------Liquid _ e ---------------------_Capacity Dis osa. geld: Distance from foundation_ 'Q_______-Distance to nearest lot line.____________ Number of lines---------- ------------------------Length of each line_________ ___�fWidth of trench______-P�_4j_:Rf----------- Type of filter material-___fof filter material--_-__1_g-________-Total length______ _1e:�i------------- Seep,.. Pita�•�.�dvistance to nea�asf'uiell ` `I}is' ancefro` oundationb Drs tar�ee�to�neare'stio" �n .__ p Lining ate-riziI Siie.'Diarr,eter7a, Depth' "' -------------- r3nber Of'`lts _-- "rm � *M" ` Cesspool: Distance from nearest well-________________Distance from foundation--------------------Lining material___-__---_----_-__-_-_______________. ❑ Size: Diameter------------------------- ------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well____-___-___________-________________________Distance from nearest building------------------------------------------. ❑ Distance to nearest lot line-----------------------_ Remodeling and/or repairing (describe):---'--------------------------------------------------------------------------------- ------------------------ -------------------------------------------------------------------------------------------------•--•----------••----•---------------------------------•-------------------------------------------------------------------- ------------------------------------------- --------------------------------------------•---------•-----------------------------------------------------------------------------------------------------•••---------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)--- Q'�Gr"` i'�" ------------- ------------=--------------------------------------------------------------------------(Owner and/or Contractor) a Sy:-_----------------------------------•--------------------------------------------------------------------------------------------(Title)--------------------------- (Plot plan, showing size of lot, 'location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY J APPLICATION ACCEPTED BY---- ---- -- ------------------------------------------------------------ DATE j__ .- ---------------------------- w" REVIEWEDBY------------------------------------------ -- ------------------------------------------------------------------------ DATE BUILDING PERMIT ISSUED-------------------- -- -- ---------------------------------------------------- ---------------- DATE------------- '/------------------------------------------- Alterations aid r recommendations______ _________ ----- --- -------- ------------------------------------------ - ------ - - ---�---�,t, --------------------------------------------------------------------------------------------- -------------••------------------------------------------------------------------- ------------------------------------ ------------------------I----------------------------------------------------------------------------------------------------•-•------------------- ----------------------------------- FINAL INSPECTION' BY:------- - -- ------- Date----___ ! - J --------------- ----- ------- �, ,� ------------------ SAN JOAQUIN LOCAL HEALTH DISTRIC 130 South American Street 300 West Oak Sfreet 132 Sycamore Street 814 North "C" Straet Stockton, California Lodi, California Manteca, California Tracy, California ES-9-21x1 . Revisea 1-57 F,P.CO.