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APPLICATION� FOR SANITATION PERMIT - Permit No. __.-_ - - - - (Complete in Duplicate) 1 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. f JOB ADDRESS AN LOCATION. I3 � . - 4 ----- -. Phone----------------------------------- Owner's Name------ -- --- --- - -- -- ----- -------------- Address--- - Contractor's Name-.42,41-7--.0Phone = :-- N. i Installation will serve: ' Residence �parfrrient House ❑ Commercial E] Trailer Court ❑ Motel [I Other [I r 3 (6- _ Number of baths--__ Lot size __-_ __ �------ ---/--fes-- ------------r_ Number of {iving units: ---_--__ Number of bedrooms _ Water Supply' Public system ®'mmunity system ❑ Private'❑ Depth to Water Table -------- ft. Adobe ardpan Character of soil fa a depth of 3 feet:- Sand Q Gravel ❑ Sandy Loam Clay Loam ❑ Clay E] Previous Application Made: Yes E] No �ew Construction f-Yes' " No❑ FHA/VA: Yes M No PP TYPE,OF INSTALLATION AND SPECIFICATIONS: ' No septic tank or'cesspool permitted if public sewer is available with 200 feet.)' Septic- an Distance ,from nearest well------------ --Distances rom//�undption-------------------.Materia--------_------------ ------ No., 'C ' mpartments----------------- ----- ` Size--- lam__-.Air_-_Liquid dep h-5- ---------------Capacity-L u -{ -+ • r l '" _� Distance to nearest lot lin ---- r "-.._Distance fromfoundation.°!- Disposa field: Distance from neares welL< f N�'smbe�of lines___ -= --- ' ----Length of each line----- � // Width of french----------�1------------------- Type of filter material- ------Depth filter material- / __/___. Total length-•-----�---------------------- of ..- . . ��.. � a- fly Seepage = Distance to nearest well__--_Q __---__Distance om fo nda#ion__________________.Distance to'nearest of fine----___-_.-___.- ' Number of pits= --------Lining material-- -Size: Diameter----- -��_--Depth--- -/___ '. _- __ Cesspool: Distance from nearest well_---__---__--__Distance from, oundation--------------------Lining material-.--.-..----------------- Size:'Diameter_- ': De.pth ------�------------------ Liquid Capacity gals- ------------ ❑ - ,.� CQI Privy: Distance from nearest well-------------------------�-- ----------- -"----Distance from nearest building------------------------------.-- •Distance to nearest lot cine--- ------------------------------------------------- - Q i l Remodeling and/or repairing (describe):--=------------- r----------'.-----------•---------------•------------------------=----•-•---------------------•----------------••-- - ----------- ---- ------------ ------------------------------------------ k -----------=---------------- •'-------------------- ------------------------- ----- - ------------------------ _ ----------• ------------------------------------------------------- I -- P-----------------�p-----•------------- I I herebycertifythat I.have Pte pared this application and that the work will be done in accordance with San Joaquin County State laws, and rules and regulations of the San Joaquin Local Health District. 4 3 ordinances. , (owner-and/or Contractor) r - (Signed) -----------------r.:-- ----•-- -=------------------------- BY: - -- =--- ------------ --- -- --• -- --- - - -- -- • -- -- ----------- (Title) - = (Plot plan, showing size of lot, location of system in relation forwells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-___} ------------------------- /�� --------------- DATE-------------------------- - - 3 ,t ------------ ---------- ---------------"--------- DATE--------------------f-�------------------------ -- REVIEWED BY------ -----=-------------------- ---------------- ---- - - ----- / BUILDING PERMIT ISSUED---•-•-- ----------=------ --- -------- DATE--------- ---••�----------------------------------------- Alterations and/er`recommendations:__----_--_ _ _ -------------------------------------------------- -' ----------------• --- --------- ---------- -- i�I _5 7 ----------- _ S _ =� a ,- ------------------------------------ ------------------------ -------------------------------------- -- .C> - - ------------- Date----=----- ------------- -----•------ -�-------------- �--------------------- FINAL INSPECTION BY:------- = j SAN JOAQUIN LOCAL HEALTH DISTRICT ! 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street 130 South American Street � Frac California Stockton, California Lodi, California Manteca, California y ES-4-2M , Revises 1.57 F-P.CO.