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�I 1 APPLICATION FOR SANITATION PERMIT Permifi No. ___ _ J__. _____ E ry A (Complete in Duplicate] (p / JpAV w , ,. _ ,_ .... _._ _ ..�.: . Date Issue �f Application is hereby made to the San Joaquin Local Health District for a.permit to construct and in-stall the work herein described. his application is made in compliance with County Ordinance No. 549... r, i JOB ADDRESS AND,LOC TIO -- -- /;-v------- ----------------------------------- Owner's Name-- ----- -•---•------------------=-------------- --------------------' ' ' ! T ;---------- Phone _s -14.,? _ ,_ --s Address.. � f .. . - --- --- --Contractor's Name------ '--------- --------------------------------------------------------------------------• Phone- ✓f� _ Installation will serve: Residence ® fA rtment House F] Commercial ElTrailer Court El Motel ❑ Other E] Number of living units: ---1---- Number ofrbedroomsljJ_— N�tuber of baths __ :_: Lot size --.-- _____________________ Water Supply: Public system Community system Private.❑ "Depth to'Water Table _V,3 Tt. Character of soil to a depfh of 3feet: Sand ❑ Gravel(❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Ig Hardpan ❑ Previous Application Made: Yes ❑ No Ie New Construction: Yes t ,No ❑ FHA/VA: Yes ❑ No to TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or cesspool permitted L public:.sewer—is_ayaila6le. 'within 200 feet.) ry Septic Tank: Distance from nearest we L_..__..___.___Distance from ou d'ation__..__ ------------Material_______________.__. a No. of compartments- . . --- Size - "-Liquid depth--------------------------Capacity------------------ -- 1 Disposal Field:. Distance from nearest we I---------------r Distance from foundation___ _--------------Distance to nearest lot line-----------L__ i © � Number,of lines----------------I-----------------_Length of each line-----I------__ ��____....Width of trench----------------------- LNJ Type of filter material----- ----------------`-Depth of filterat al-----_--- _'---------Total length--------------------•-----------._._-- _ Seepage Pit: Distance to nearest weft d �_. Distagce from foundation_: j Q......___.Distance to nearest lot e_:_a.......... l Number of its ------1.._ /---------- w / p r _Lining matenal___�r1�/_�_____Size: Diameter_..{,��'_ __________ Cesspool: Distance from nearest well-------------- -Distance from joundat.ion-----_ ,---_-----_.Lining material---------------------------------.._. (A� i ❑ ' ..' Diameter Depthf *. ------Liquid Capacity ---------- gals. + welroerivy: Distance from nearest } _ ncmarest S building___ _____________________ l ❑ Distance to-nearest lot-line-------------------------------------------------- ----------------------- ---------'---------------------------------------- Remodelin and/or repairing describe a_V.Al2f._____-A ' G� -P--- --- -------'fes ---- -fAP--[ --�9 ---------------------------------------,--- ---------------------------------------- - ---------------- -----: . I hereby certify-that l 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. ., Y i + (Signed // --- ----------��!�'--------=------------------ ----------------- ---------- ----------------r-- ------------(Owner and/or Contractor) d� BPf"t__ °''yz f�cL�rE9g --------- -_t ----- -- ------------------------ Title - pw.:`='�� r I (Plot plan, showing siz�f lot, location of system in relation to wells, buildings, etc., can be placed on reverse sideJ. ° FOVDEPARTMENT USE ONLY APPLR EVIEICATION WED BY-----------------------------------ACCEPTEDBY --- --�--------- - - --•- -- ---- ----:----- ----------------------------------------• DATE_..------------ --�- ------------------- REVIEWED ------------ - - � -------- --------- ------------------- DATE -------------------- -------------------------------------------------- ------ BUILDING PERMIT ISSUED------------ a DATE: l� - --- - ------- ------------------------------- € Alterations and/or r o mendati ns: ----•------ --- ------------------------------------------------------} - d S. r E -----•----•--------------------------------------------------------------------------------------------------------------------------------------s---------------------- --------------- ---------- -----------•-••-----•--- ------•------------•----•---------------------- - --------------------------- --------------- I—— •---------------------------------.-....-----..---------------------------•------ r , .� FINAL INSPECTION BY: :. -----------=- ---� _ Date___ - - s1. --- ---- „ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street ;814 North,"C" Strait Stockton, California Lodi, California Manteca, California ;,Tracy, California:- ES-9-2 M alifornia:-ES—R-2M Revisea 1.57 F.P.CO.