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11A �� ' r� E. t + Permit No. _-. x '1j APPLICATION FOR CITATION PERMIT /S /!" (Complete in Duplicate) 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. [ L __ W%rz�44-------------------------------------------------------- ----- ------------------------------ – �---- :: r.. ------------------ - ,.:.-JOB ADDRESS AND LOCATION- --------------- ----- 2.JJ _______,-.-- Phone-------------------- Owner s Name------ - -,Address---- -----------------------------------------------------�-------•-------•-------- ------------------------•-------------- v . .----- -.. ------------------------------------------ ---� Phone 1 Contractor's Name----- ---------------- Motel Other [3(] Apartment House Commercial ❑ Trailer Court ❑ Installation will serve: Residence a ❑ 1 Number of living units. A---- Number of bedrooms .�--- Number of baths ---I--- Lot size ... .r - ---------------- Public system ®'Community system ❑ Private ❑ Depth to Water Table--- ft. Water Supply: Y Clay Loam Clay ❑ Adobe t]�dpan ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Y ❑ I Previous Application Made: Yes ❑ No few Construction: Yes ❑-110 T-1 FHA/VA: Yes ❑ 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 well.................Distance from foundatidepth__Material--_--_---_Capacity...--_---------------- 7 No. of compartments--------------------------Size---------------- - Liquid Disposal Feid- Distance from nearest well-----------------Length oftance reach line om anon__--_------------.__DW Distance oftfrench----- lot line----------------- Disposal l Number of lines------- - J Total length------------------------------------------ Type ------- --- ------ ------------------- ` Type of filter material-------------------------Depth of filter material- -. y Seepage Pit: Distance to nearest well__.- _L�!_"' --__._Distane�rom foundation.i!`!-fiJ�.� ----•.Distance to nearest lot line.-``---------- Size: Diameter----�`- ---- --- --.Deptn----�3.�.-----••------------ � t Number of pits.---.1----------------Lining material --------- Cesspool: Distance from nearest well_.-.----- Distance from foundation....................Lining material------------.--------------- \ -Liquid Capacity gals. ❑ Size: Diameter------- -----------=----- ------ P Distance from nearest well ---------------------------------Distance from nearest building---...-._..----------------------------- ., _ _ _ --------------------------•--•-------------------- ------•--------- ------- --- ---------- rest Distance to near he lot line + n {`_ ; OYU.- -g �l`!---------------------" --- ------- �• 154. Remodeling and/or repaEr;ng (desc �' V - - �+ i.i�.._�•!.cls'1----------------------------------------------------`-------'-----:-------•-------------•-----------------.------------------`-------------------------•--•-----•-------------------------------- ---------------------•-------------------------------------:------------------------------------------------------------------------ --------------- I hereby certify that I:hava 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. Si ned 7. : ' " (Owner and/or Contractor] -------- ----- ----------------------------------- ---- _ .. ( g t 4 --- ------- - v� . ..,� L«. , --------------------------------- -----------------------(Title)--_ By:-------------------`�" j-------- (Plot plan, showing size of lo �location of system in relation to wells, buildings, etc., can 6e placed on reverse side]. ( FOR DEPARTMENT USE ONLY 'r'S� APPLICATION ACCEPTED BY--------- --------------------- ------------ ---------•--------- --------- -------- DATE---- ------�--•--- ------------------------- - REVIEWED BY------------------------- --------------=---- ----- ----------------------------------------------------------- ----------------- DATE-------------------------------------- -----------•---------- BUILDING PERMIT ISSUED.--I_-----•------------------------------------------------------------------ ---------- Alterations and/or recommendations:-----✓-��--------------Z�i--------- ------------------------------- f °` ' I ------------------•----- - ---•--- ------------------- --- ��o- es---- _-------F---------------_--------�-----------------------e------------ Date-------- ------- FINAL NSPECTION BY:.---; -----• - --------------- ------------ - ' SAN JOAQUIN LOCAL HEALTH DISTRICT , i132 Sycamore Street 814 North "C" Street 130 South American Street 300 West Oak Street Trac California Stockton, California Lodi, California Manteca, California y' ES-9-2M Revised 1-57 FY CO.