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FOR OFFICE USE'S - __ ____ _ __ ___ ___ ________ _________ n F i1 APPLICATION FOR SANITATION PERMIT Permit No. A/�- -------------------------------------------------------- -------------------- [Complete in Duplicate) -------------------------•- -_=------- Date Issued ------------ ------------------------------------------- This Permit Expires I Year From 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 Ordinanc No. 549. JOB ADDRESS AND LOCATIO as / - 1 ------------ ----------- `-------- Owner's Name , -- . __ CQI`',�� !.--- Phone---�--- --- `l d Address--�---� r `u'``� ( {f "- -- •----------------------------- •-•--- . ,�` > Contractor's Name' ---- - -------------- --- Phone*�. 41 =-;U' .! In I allation will serve: Residence Q]/fS'partment House E] Commercial Trailer Court E] Motel [I Other ❑ it Number of living units. _1-____ Number of bedrooms __yNumber of baths __/.-__ Lot size ___. ___. . _----.-__--_ Water Supply: Public system �Kommunity system ❑ Private ❑ Depth to Water Table -------- ft. � a Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ ;,\ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ No FHA/VA: Yes ❑ s No ❑ TYPE OF INSTALLATION AND SPEC,IFICA ,IONS:_ €i [No septic tank or cesspool permitted if public sewer is available within e 20.0 feet.) I Se t'cf Distance from nearest well-----------------Distanceam�foun„d'a ion____-_._.___----.--.Material-_____-..._----_--------------.-_--. _- ----- �+ I N _ __` --Liquid de th_---_ Capacity ! i No. of com art�ents_ _Size_-.--..- _--_-. Di s oqa :G Distance from nearest well j jLl�_Distance rom'{o n'dation__�_.-_____Distance to nearest lot rine--- _a:_ ff��_t,Length of �V� ,. ----__.Width of trench._-_Z_�_`�----.-_---.r� �'. Number of iines�_ �.____ g each line_ /'° I Type of filter material r Depth of filter materiaL__I_ ..notal length--------------------- _l! _�.:,__E_� Seepage t: Distance to nearest•wellD_ Q_ ` I's ta Number of it .� ___Lini'n� mDteaal ro o zonD __P____.Qistancto nearest lot line_�_ � Ipits.. �. g: sC tern,,,,]% --- Depth - ---------- I p '+ i Li ..uid Ca ac CaG- Cess ol. Distance from ea rest weli_____�_-_.E�___DIst �ce from foun ion____-_--- Linin maters EI - --------- rr � � � q Capachy----------------------- gals. 'I f1 --------------- i II © Size. Diameter-- - --------------�_--.Depth-- -__-- D�stnnce from Priv Distance to neareatelo�line - ---------------------------�s a-�eOfra nearest building_- ----------.-_------------- ---.--___-- t I --- Remodeling and/or repairing (desceibe):- I 4 - - -� _ _____ __ _.- __._• ---_--- _ 1 itI: i - _____.. �" ______________�+.t-------------------------- -------------._-..-.-.___-.-.____-____ ---------------------------------_----------_ ..-.-_.._ . ti. 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 n Joaquin Local Health District. [S1gned)_�'�a } ---------- -- Contractor) IS BY -------------(Title)------------------- ------- --- - ----- - -- ------- --------- •------------------------------------ t: (Plot plan, showing size of lot, location of systemkin relati to wells, builds s, a ., can be placed on reverse side). 1 1 t ` FOR DEPARTMENT USE ONLY t APPLICATION ACCEPTED BY......... e C -------------------------- DATE--------- p -- —2-:5 - --- -----------{'y REVIEWEDBY------ -------------------------------------------------------- ---- - -- --------------------------------------------------.. DATE-----------------------------------------------�------ - .. BUILDINGPERMIT ISSUED------------------------------------------------------ --------- ------------------------------------ DATE---------------------------------------------- ------- Alterations and/or recommendations:---------------- ----------- - ------------------------------------------------------------------------------------------------------- '-------- 19 -- ----------------------------------------- ------------------------------ --------- --------------------------------------------------------------------------------------------------- ------------------------------------ ---------- ------------------------------------------------------------------------ il EI !1 �� /c FINAL INSPECTION BY---------------"- ---- ---------------- --- - ..... Rate ----------1--l-f- - -----%--`----------- - ------------- SAN -- --------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street 11 Stockton,California Lodi,California Mantecar California Tracy,California f� F.P.120. ' �I