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,CIS k" Applica�ion 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 ADDRE AND LOCATION____------- 3 -------- I -g 15 {d ,6 ----- 1/ - ---=------------------------------------------------------------------- ----------------- 11� Y Phone ---------•-------------------------- Owner's Name ------�I :Q�+ 1----------.��Q� �'.-t ti� - Address ----- --�.-11-3------------ ---D ------ L>!;_�c'------ ---- Phon - - - -------------- Motel ❑ ❑ Contractor's Name---- -7---�-----•-'-`-� -- --�----- -- ------ -- - ----- --- -- ---- -- - --- - Other Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Number of living units: ------ Number of bedrooms ---L Number of baths I---- Lot size------------------------------------------------------------ 01 --_-_._. 0 APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Permit No. -------- Date Issued -/ 4-hh --- Water Supply: Public system ❑ Community system , +� rnvalr, L -i • -•- Character of soil to a depth of 3 feet: Sand F1 Gravel [I Sandy Loam ❑ Clay Loam [I Clay E] AdobeI Hardpan ❑ Previous Application Made: Yes ❑ No ® New Construction: Yes PQ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank -or cesspool permitted if public sewer is available within 200 feet.) • -- Septic Tank: Distance from nearest we Distance from foundation....-' - � 0 --------- Material-__ ' Dis_--- Disof compartments -- Size---- x S -----------•---Liquid depth --- 0 ------------------Capacity-•----. Field: Distance from nearest well --_..._-.__..._.Distance from foundation_.__.. o--�_.--.Distance to-hearest lot line___ + --.-- Disposal� ® Number of lines ------------- /------------------- Length of each line--- f ------Width oftrenchs : Type of filter material------------------------- Depth of filter material------�-----------Total length------.--------------- -- Seepage Pit: Distance to nearest well_______ r_ ------Distance from foundation___._3-------Distancp to nearest lot line,_ /�------- ----------------- Number of pit.___...__ -/__..------Lining material --Size. Diameter -------- Dept m material p . (V Cesspool: Distance from nearest well ----------------- Distance from foundation -------------- mapaiity-------------------------------------- Cesspool: _ __-----.___.___----________ .Li Liquid Capacity gals. (All ❑ Size: Diameter------------------------------------Depth-------------------------------- --- q p Y -- "Ai Privy: Distance from nearest well ...... ............. .----------------------------- Distance from nearest building ------------------------------- ---- - ----------------------- ---- ------------------------------------------------ ❑ Distance to nearest lot ine................. . ------ - ----- - , Remodeling and/or repairing [describe): -------------- - ------------- - ------ --------- ---------------------------------- ------------------------------------------------------ -------------------------- I, hereby certify that I have prepared +his application and that +he work will be done in accordance with San Joaquin County egulations of the San Joaquin Local Health District. ordinances, State laws, and rules and r • �(Owner and/or Contractor) (Signed].. ars' ---- rf C_r` -(Title)------ --------------- ------ (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 --------------------------------- DATE- ------------- ••------------------------ } , APPLICATION ACCEPTED BY- DATE--------------•---------------•-------------------- t ---------------- REVIEWED BY ------- - ------------------ BUILDING PERMIT ISSUED ------------------------------------------ ----- -------------------- ----- DATE---- ----------------------...----- Alterations and/or recommendations -------- --------------------------- ----------------•---------- •------ ------------I---------•------------------------------- ---------------- ----------------------------------------------- ----------------- --�---------------------------� Date_ ------ ---_ / "_ -------------------------------------------------------- FINAL INSPECTION BY.-_.-______.._-___._ - - SAN JOAQUIN LOCAL HEALTH DISTRICT ! 300 West Oak Street l32 Sycamore Street 814 North "C' Street 130 South American Street Trac California Stockton, California Lodi, California Manteca, California Y� E