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AN-LICATION FOR SANITATION PERd, f Permit No. (Complete in Duplicate) `1Z tai Date Issued .---- Application is hereby made 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 Ordinance No. 549. JOB ADDRESS ANDLOCATIO I, --- q------ ------------------------------------------------ Owner's amePhone---------- ------------------------- ----------- Addrf =1,--------------------- _V Contractor's Name---PAY_ ----27E----- --------------------------------------- Phong&_,g 44/ Installation will serve: Residence E] Apartment House E] Commercial ercia Trailer Court ❑ M I El Other El 13 0 El If' Number of living units: -------- Number of bedrooms -------- Number of iths -------- Lot size ___________________________________ Water Supply: Public system ❑ Co system ❑ Private Number to Wafer Table ft. ..... ............ Character of soil to a depth of 3 fee . Sand E] Gravel E] Sandy Loam E] Clay Loam F1 Clay E] 'Adobe 2'- Hardpan 0 Previous Application Made: Yes iNo F] New Construction: Yes 0 No FH A. /VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: No septic tank or'cesspool permitted if public sewer is available within 200 feet.) eptic an . Distance from nearest well-----------------Distance from foundation---------------------Materia�-------------------------------------------------- t4,_iL No. of compartments----- Size--------------------------------Liquid clepth------------ ---------Capacity----------------------- s,6111 i jd: Distance from nearest well-- -- ._.----Distance from foundation--------------------Distance to nearest lot line--__-_-_..-__--_- Number ine----------------- Number of lines------------*----------------------Length of each line-----_-------------------.---.Width of trench.-------------------------------_-- Type of filter material_-_-__-_---___ Depth of filter material------------------------TofaI length------------------------------------------ Seeps Pit: Distance to nearest well.106_---__.__-Distance from to nearest lot line---10------ Number of pifs.--,2-------------Lining material--N.I. .........Size: Diameter____ ,----- --_.Depth:_ .-------------------- 4 Cesspool: Distance from nearest well----------- ---Distance from foundation--------------------Lining material--.-----_______________------__.-_ ❑ aterial------------------------------------- El Size: Diameter-------------------------,---- ------.Depth------------------------------ -----=-------------------I-----Liquid Capacity----------------------------gals, Privy- Distance from nearest well____----------- --------------------------------Distance fro nearest building. ----------- ------------------------- .......... ..... ..... ........... El Distance to nearest lot line-_------- -------- -------- ------------ ------------------ ------------ ------------ ----------- ----- --------------------- Remodeling and/or repairing (describe): --- ----- - - -------------- ------------------------------------------------------------------------------------ ---- --- ----------------------------- ------------------------------------ ............. ---- --------------------------------------------------- -----------------------------------------_-.-1---------------------------------------------------------------------------------------------------------------------m----------------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 laws, and rules and regulations of the San Joaquin Local Health District. (Signed ---------------------------- PWA1111 Contractor) BY:--------------------. -----------•-- ---------------------------------------------------------- ---)Title)-------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation tow , buildings, can be placed on reverse side). In FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED DATE BY----- REVIEWEDBY--------- . 1�1----------- ----------- ------------------------------------------------------------------- ------ --------------------------- --------------------------------------------------------- -----------------------------------------I----------------- DATE BUILDINGPERMIT ISSUED-------------------------------- --------------------------------------------------------------------- DATE---------------------------------------------------------- Alterations and/or recommendations:_-----_------_._----_------------------------ ----- - -1-----K--- 5 ------- --------------------- ---------- zyu ------- ------ YRF------- ---------- I--- - ----------T_ -------------------------- -------PEI>_ JAP_5f>�---C.- -co-K! -------- -- --------------- -------------------- ------------------------------------------------------------------------- ------- ----------------------------------------------------------------- ----------------------------------------------------- -- ---------------------------------------w------------ -------------------------------------------------- ,. ------ -------------------- ------------------------------------------------------------------------------ -------- ------------------------------------- -- ----- ----- --- - ------------------ -- -- - -- -------------------------------------------- --------•----•-- I----------- IN/ FINAL INSPECfiIQ. ------------------- By:_ Date--- ----- SAN JOAQUIN LOCAL HEALTH DISTRICT F 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lod;, California Manteca, California Tracy, California ES-9-2M Reviseci 1-57 F.P.00.