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APPLICATION FOR SANITATION, PERMIT Permit No. (Complete in Duplicate) l 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 County Ordinance N 549. JOBADDRESS A OCATI 7 .. ------- r ------------------------------------------------------------------------------- -------------- Owner's Name---- ---'-- '--�---1 -'- ----•---------- ----•------------=------------------------------------------------------- Phone- ---------------------------------- Address - ------------------------- w I Address---•------------------- - � .�;rj -------------•-••------------•--••------- Contractor's Name --- -- ----- -----------------------------------------------a' 9.. Phone Installation will serve: Residence Apartment House❑ Commercial ❑ Trailer Court ❑ Motel ❑ then❑ Number of living _.I.--�, mbar of bedrooms __, ...Number of baths __ --- Lot size ._._=f%. ..x.�..... _---------------------- units. I Water Supply: Public system Community*sy,stem"❑`;Private❑' 'Depth to Water Table --------- _-- -'.ff. Character of soil to a depthf 3 feet: (Sand.E] Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ .Adobe Hardpan ❑ Previous Application Made: ,Yes.❑ rNo [ New Construction: Yes No [] FHA/VA: Yes_❑ No TYPE OF INSTALLATIONr AND SPECIFICATIONS: , � ..-i �.. (No septic tank or'cesspool permitted 'f ublic s er is available within 200 fee .) 1 e from nearest 'ell) Zistanc fro ung ion�fJ__.-.__......Materi`L --------- , ��. Septic nk: Distanccom art{ments.. __---,.. t '_ ize :x _ �`�---Li Liquid eptn--`-------- - - Capacity--- �.r� No of p � q -' Dispos Field: Distance from nea est well '% • ..Distance from foundation) " Distance to nearest lot line . I T i� Number of lines__'.'.......� ... .. ......... .Len th of each line-------_. . Width trench..-._-.-_.7u_ a g 7t Type of filter materiaepth' of.filter material---------1._.9-..._..Total length__..._-----... _ .Q...__..__.. Seepage Pit: Distancelto nearest well" -".......:.....:..Distance from foundation--------------------Distance to nearest lot line----------------- ❑ Number-of pits---------------------Lining material---.,.'`''__..:t --Size:.Diameter----------------I-------Depth to Cesspool: Distance,from nearest well-----------------Distance f o foundafion...._-----_____-...Lining material-_-____...._------.-....-..._........ V qDi eter.- Capacy g . Diu _�Nl Privy: Distance from nearest well.. _.... _. .... '�" " ! - -Distance from nearest building____ -- --------------------------- ---- Distance:to nearest lot,-line'....-..:__.r_ __.. - --- ❑ t. .- If ---•------------ -- i ; Remodeling and/or repairing (describe):- _'---------------------------,______.__. ---------------------- .. . i. --------------------•`-------------------------------------- I herebycertifythat I have re ared,this-a lication and J Y -- ---- -- ----- - -- -- --------- pp d..t)iat the,rxork will,be_donerin,accordance with San Joaquin County ordinances, tate lws, and rules and re ulations of the San qui '.Local Health District.- . ..� (Signed) ' j {Owner and/or Contractor) By:----------------------•--•----------------------- ------------------------------------ ----------------------------- ------------(Title)-----------•-----------=------------------------------ ---- (Plot plan, showing size of lot, location�f system in relation to wells, buildings, etc., can be placed on reverse side). - .z FOR"DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .. ._. . - ------ . --- --------- DATE,----- --------------------------------------------- WE BY = _ ;,. DATE ------------------------- REVIEWED -------------------- ----------------- PERMIT ISSUED--------------------------------------------- ------=-----•--------------r-.-:.. --------- --- DATE.. ,�� ------------------------------------ BUILDING , :�--'° Alterations and/or recommendations--------------------------------------------------------"----- --------------- --------- •---------"-----"--•----------------= 1 ..........................................................I---._....-_-------.---.--------- -- ------------------------------------------------ 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-9-2K4 Revisea 1-57 FT.CQ.