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PLICATION FOR SANITATIO , RMIT Permit No. j� �.0-... (Complete in Duplicate) o o 6 - Date Issued AP ti6in-is hereby ade 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 Ord`iilnance No. 549. �y //,/��u -j JOB ADDRESS A LOCATION----- - -------------------------------------- ----------{{YY.. __V----- r�---- ----------------------- / /f Phone Owner's Name------Y ,r✓ A, �-�---------/_ ) --�------•------------------------- Address------------- __ �_ Cr` , �'---- - ------ ~� t`7s�� ------------------- ------------------------------------ Address -- I Contractor's Name------------------ ---------------------------------------------------------------------------•---------------------- Phone----------------------------------- Installation - ------------ •.--------------- Installation will serve: Residence �� Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _j- Number of bedrooms _P'�__ Number of baths I____ Lot size �__�__,�----1-411------------------------- Water c-----_ ---Water Supply: Public system ;X 'Community system E] Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe,V Hardpan ❑ Previous Application Made: Yes ❑i No jZ_ New Construction: YesA No ❑ FHA/VA: Yes ❑ No I _ 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_?Z_�_1! Distance from founds o�_AD_f________.Material____ r No. of compartments----- `--_-----_-. -- Size-� -- -_- .-.e_Liquid depth--- ------------------ Capacity_- 1' -- Disposal Field: Distance from nearest we11 1- istance from founds ion_O&'/ _ � /� �� ____._.Distance to nearest lot lm��___-_. Number of lines_______ _: _____. Length of each line-_��.a__ -------------Width Width of trench___ _ � __________j_____ fr � Type of filter material- _--_______Depth of filter mat enal_ _______________Total length--- ------------------------ Type Pit: Distance to nearest well__________________-�_Disfance from foundation--------------------.Distance to nearest lot line------_.---_----- ❑ Number of pits----------------------Lining material-----0-- ---;`Size: Diameter-------------- --------Depth--------------------------------- Cesspool: Distance from'nearest-well_____-_--_____+Distance from,foundation____________________Lining material_______________-_.______-_-- Size: Diameter-------------------------:--- - --------------------- -----Privy: from _____Distance from nearest building y _, . �-_--- � ❑ Distance to nearest lot line---------`-------- ---------- -----------------------------------------------------=--------------------------------------=---------=-------- Remodeling and/or repairing (describe):------------- 4-----4----------------------------------------------------------------------------- --------------------------- --------------------------------------- -----------------------------•--------------------------------------------------------------------------------------------------------------- �s ------------------------- --------------- -------------------•-------------------------------------------------------- ---------------------------------------------------------------- i I hereby certify that I have prepared this application and that the work will be done in accordance`with San Joaquin County ordinances, State la and rules and regulations of the San Joaquin Local Health District. Y(Signed]----- )-ir---ur-�_ 1---------------------------------------------------_.----------------------------(Owner and/or Contractor) B . 1 (Title) 1 Y•----------------------------------------- - (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 --------------------------------- DATEAPPLICATION ACCEPTED BY_____________- __._.__ _-_ __.J-7 _REVIEWED BY -- ------ --------------------------------- DATE-- r`` ��BUILDING PERMIT ISSUED---------------------- `-- ----------------------� - ------------------------- DATE------------------------------------------- Alterations --�------ - ------ ----------. - Alterations and/or recommendations: fz_r. :y { �� "-�'- -- --------------------------------------------•-------•----------------------------------------- P - t.�tuz 1 >"�Grr = -------- o _fn aR_ ---- -------------------------------------- 315-.---- �'- t' ` o-K �,�! r - -may N�>✓T ��----- C __N1_�C:�-�-------] I � r/-/W-,f� --- FINAL INSPECTION_BY__.� �, = Date: -- ---- -- --------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES--9-2M Revisea 1-57 F.P.CO.