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APPLICATION FOR .SANITATIONQQ PERMIT Permit (Complete'in Duplicate) ' Date Issued 2,f X-- —Oft...f s. ! Application is hereby made to the San Joaquin Local Health District for a permit to construct and install t This application is made in compliance with ounty Ordinan No. 549. ork herein described. 7r3'1 VJ: L.1 ni.:1 E ,�� y , JOB ADDRESS AND OCATION --------- - , ---------------- Owner's N me - Phone_ Address_-------- •- --- ------------------------•-------- Contractor's Name--_-__-- -_ .. -- -------••- -----------•--- ----- , - --- /!7}Js ¢ r --- ------ - ---------- -- -- - ------•-------- Phone _ Installation will serve: Residenceff Apartment House'❑ Commercial Ej Tra�I r Court El Motel ❑ Other Number of living units: ___l-___ Number of bedrooms ._�- Number aths I7:' Lot size � � Water Supply: Public system Y ❑ Community system ❑ Private Depth to Water Table ___"__"_ ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam Clay Loam E] Cla Previous Application Made: Yes No Y El Adobe Hardpan ❑ New Construction: Yes No ❑ . TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public Sewer is available within 200 feet.); Septic ank: Distance from nearest weiLQ __Distance romoundatio ._ _ � I -i Mater 1- No, of com artments_ qq + p J Size_p _�Liquid deKh---------- F ------Capacity---�-'-- _---_. Disposa Field: Distance from nearest weilAIP -Distance from foundation __ __ """ Distance to nearest lo});W_ / Number of lines______________ Length of each line_______ Width of trench ' Type of filter material__ ____ __ -Depth of filter matenaL___-___�_- Seepage Pit: Distance to nearest well________________ Total length_________ __ -- ____Distance from foundation____________________Distance to nearest lot line___-__._-________ ❑ Number of pits___:_______________Lining material-----------------------Size: Diameter-----------------------Depth-- ---------- ------=------- Cesspool: Distance from nearest well-----------------Distance from fo0ndation--------------------Lining material------------------------ El Size: Diameter------------------------------------Depth--- -------------------------------------------- -- r Liquid Capacity----•-------------------- -gats. .r �Priv _ .�........a....�...�_.. _..g. ❑Y Distance from nearest well------------------------------------------------Distance from nearest building___________------_----- Distance to nearest lot line__ _ ------ ------------ Re delin and/o repairin [describej:- -9 x �J 1 ---- ------ r... r _ .. •------ --- -------- - -------------------------- 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)-.-- --- 1 - ------ ---- BY6� - --- ----------------------------------------------- (Owner and/or Contrac -f' __---- =----(Title)-------------- ---- d/a or) (Plot plan, showing size o*Colocation o system in relation to wells, buildings, etc., can 6e placed on reverse side). n FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-'---- i �.y ------ ----------------- ED ---- DATE_ REVIEWED BY :-------------- - � ,-- --- BUILDING PERMIT 1SSilED -------- DATE--- Alterations and/or recommendations---------- ------------- DATE--- \ -----"--- ------`------------------ --- ---- --------------------------------- ---------------------------------------- ---------------------------------------------- --------------- - --------------- FINAL INSPECTION BY -------------------------- �j�'_ ----------- r SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak S+reet f 325yeamore Street 814 North "C" Streef 1 S+ock+an, California Codi. California Manteca, California Tracy. California ES-9-2M 8-51 Revised W-2100