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1 APPLICATION FOR SANITATION PERMIT Permit No. I-��' (Complete in Duplicate) Date issued_--«- on is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. 1 Application y ' ! This application is made in compliance with County Ordina e No. 549. i JOB ADDRESS AND LOCATION___A,.. _.�.�---- --�-, - -- -- -, --�"-- �-� "--•• --� � �� / Phone -�- _- = ' --� Owners Name ----- ------ �. . � - - �ti -•--•'--------_- ------ ---- T ------ / Address----------- --- j p f` ,— X� �- ° ��'- --- --- - - hone - t'y, Contractor's Name -------.______. "�"-- - Installation will serve: Residence �' Apartment House _ Commercial ❑ Trail r Court ❑ Motel ❑ Other ❑ "� - If 11Number of baths__ Lot size `..�'-- �-"�- ------------------- Number -- -- ---- Number of living units: --- .__-. mber of bedrooms _ Water Supply: Public system Community system ❑ Private E] ,Depth to Water Tableft. ! f P Character of soil to a depth of 3 feet:' Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ ,Clay ❑ Adobe „ Hardpan ❑ Previous Application Made: Yes ❑ Noy � New Construction: Yes .❑ . No ❑ FHA/VA-.Yes ❑ No TYPE,Pf INSTALLATION AND SPECIFICATIONS:.. No septic tank, or'' cesspool permitted if public sewer is available within 200 feet) Y - f _ ._; ��Distance from nearest well : _. Distance from foundation. Material eptic Tanlc .�� o of coin artments _Size----- ----- ------ Liquid depth - --------------------- Capacity--- i D� sal Id_i ;Distance from nearest well__ 4'�Diatance from foundation"_ _.Distance to nearest lot pne,�-. ' °---- Width of trench �. Number of lines_._"__I_" �-J Length of each line_"_' _ Q. �; _--. Type of filter material € Depth of filter material.. -.fir_ ..Total length." 1�`a---_ _ r �- - � �_____ Distange to nearesflo�t line ---- _-_. _-- Seepage _ S tion .."' See • a e Pit: ':� � p g Distance to Peares�t' well_.._.". g Distant from foundaze: Diameter___-�d��a Depth_-..�vc�.a Number of its Linin material�� ce from foundation ---------Lining material --..-------------------------------- Cesspool: --- ----- N Cesspool: Distance from nearest well _-- -._- ------ DistanLiquid Capacity ..__gals. ❑ Size: Diameter + ---- - -- Depth '---- -- --------- -' q P Y _"_ -Distance from nearest building Privy: ' Distance from nearest well,_ --- ----- ----- -- ❑ Distance to -nearest, lot Im� ._-- _---- -" ==; Remodeling and/or repairing (describe): - ��' -------- ----------------- -- --- ------------------------------------- --- t r'--------------------- . ----- ------ ---- - - ------ "---•-- - •- ---- '' I hereby certify that I have prepared this application and that the work will be done in,accordance with San Joaquin ounty ordinances, State laws, and rules and-enij iQg Afe San Joaquin Local Health District. AY a Se tic q islc Service a-4g�rContractor) (Si ned f�� i --HO Z'(f�4� g ) ? �! TitleBY�---••'-- -- Stocktoa, Calif__ , - ----- jah �` --( )----- --------------- ------(Plot plan, showing size of lot, location of system in relation to well buildings, et can be placed on reverse side). t T FOR DEPARTM, NT'USE ONLY '�.� ------------------------- DATE --- ----------------------------------------------- APPLICATION ACCEPTED' BY------------------------------------------- -- --- -- -- DATE----' . REVIEWED BY---------------------------- --------------------- - --- DATE----- ---------- ----- BUILDING PERMIT ISSUED -------------------------------- = = ' DATE----------- ---------- ---- ---------------------- BUILDING - ------ ----- Alterations and/or recommendations: ------- ._"--------------..----------- =------- ---- ---- ----------------- ---------------------- ___ __________ __c_ -- FINAL- INSPECTION- BY:"- ---==-----------=-------=---- --- ...' SAN JOAQUIN LOCAL HEALTH DISTRICT 132 Sycamore Street 814 North "C" Street 130 South American Street 300 West Oak Street Y Trac California Stockton, California Lodi, California Manteca, California Y. ES -9-2M - Revised 1.57 P-P.CO.