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r� Ilk t ti Permit No. � APPLICATION FOR SANITATION PERMIT v� fQ V (Complete in Duplicate) 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 AND OCATION /_ 4V�' - �' `� = ------------------------- Owner's Name----- fl / ---- ----- •--------------------------- Phone Address ��- — ----- ��' ` = .... Contractor's Name--------- - X4 - i Phone �r Installation will serve: Residence I- Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:°__-/-_ Number of bedrooms __ __ Number of baths _/__ Lot size __- __ x- / a , Water Supply: Public system 1E] Community system WR*'0`Privafe ❑ Depth to Water Table _�Yrft. Character=of soil-to a depth of 3 feet: Sand E] Gravel E] Sandy Loam El Clay ❑' Clay ❑ Adobe 931 ardpan ❑ Previous Application Made:.Yes ❑ No New Construction: Yes g�TNo ❑ FHA/VA: Yes E I\o ❑ 4 TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) � C— Septic Tank: Distance from nearest well_,1AP--__Distant ff rom foundation----/0--____.-_ �1,a/te�a---------------------� �� __-__.__ -..�-__ tJv No, of compartments-_----�__.------------Size_ (!__X_Y�.-__Liquid depth-__-I' Capacity_--�p -� ' .. � Disposal Field: Distance from nearest we1l/e_169:2�:._.D.istance from foundati n_=_- --------Distance to nearest lot link__�___----- Number o linmatena /__ e gh of filach line---- "-__-�[ Width of french ______ _ _ .____ Len th of e Type o i e f & p ter mate rial----��---_--- -Total length.--- �---------------------- Seepage Pit: Distance to 1 neareselC lPe_----Distance/fom f dation_-___fs�______.Dt cp to Dnearest _.lot _—!.___/__ rNumber of pits____�____________Lining material _.Size: Diameter___ U`------ Cess -____ Ces�ol: Danearest well-- - =- - Dstnce from foundation_ -- ::::: : Lining material------ ------------------------------ - Size: -- -- ---- Dep - :__ _Liquid Capacity----------------------------gals. Privy: Distance from nearest well------__-----------------------------------------Distance from nearest building----------------------------------------- -------------------------------------------------- . Distance to nearest lot line- --------------------.: :---------------- ------- ----` ---------- Remodeling and/or repairing (describe)---------------+rte -'�r� - -- -- ------------------------------------------------ ------ ------------ - r , -----------•---------•----------- ---------------------------- --------------------------- 0 • -----------------•------- -------------------------------------- --------------------------------------•-------•---------- ----------------•------------------------------- ------------------------------------------------•- --------------------------------------------------------------- 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. i Si ned -R.,.. ''' ---(�r Contractor) ----- Title a � ' By:----- -------------------------- } ! 1 (Plot plan, showing size of lot, tion of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- - - ---------------------- - ------'----'------------------ ----------------- DATE----- •----•----'-------- ---------- -------------'--- REVIEWEDBY---------------------------------------------'------------------- ------------------------------------------------- --------- DATE-----------------------------------------_---------------- BUILDINGPERMIT ISSUED--------------------------------------- ------------------------------------------------------------- DATE----------------------- Alt tions and/or recommendations:------------------------------------------------------------------------------ ------------------------------------ � -------------- A ------------- _ - -�•-- ---------------- ------------- --------------- ------------------------------------ ----- :: ----P - ---- ---'--------- ------------------------------------------------------------------ FINALINSPECTION BY------------------ ---------------------------------------------- Date-------------------- - -------------------------------------------------------- _ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ' 300 West Oek Street R at 132 Syemore Street 814 North "C" Street F Stockton, California Lodi, California Manteca, California Tracy, California r� 1 ES-9-2M Revisea 1.57 F_P,CO.