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ARW 1N� AP�PLICATiON'FOR"SArNITATION PERMIT Permit Na. (Complete inDuplicate) 5 J i Date Issued Application is hereby made14o 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. JOB ADDRESS AND L TION_ Owner's Name =-` -- --------------`="r" --------------"`Phone ----------- Address------ , -------------------- -------- I` ' -------- ------- Contractor's Name------�----- 'A- �_ --------� ----- • ----- D. .. --- ❑ Phone -�-----�----- Installation will serve: .Residence A artment House Commercial ❑ Trailer Court E] Motel El Other [INumber of living units: Number of bedrooms ---1_ Number of baths Lot-_f ry t -=-- 6- ---��----- ---------------"-- Water Supply: Public syste'IIm �ommunity system ❑ Private ❑ Depth to Water Table -$V ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loalm ❑ Clay Loam ❑ Clay ❑ Adobe®- :il rdpan ❑ " Previous Application Made: 'Yes-ElNo [ New Construction: Yes E'] No gj-�FHA/VA: Yes ❑ i No El TYPE OF INSTALLATION AND-SPEC IFICATIONSr (No septic tank.or'cesspool permitted if public sewer is available within 200 feet.) Se to :r Distance;,fro� Barest well_ ______________Distance from foundation_-___-_-____-----.Material-"--�____-___..__-__-_____________ ____.___. �' Qmpartrnents------ --------------- ------ i Size Liquid depth -----f-- Capacity----------------------- a pI ._ Dis osI Field: Distance jrominearest wel------------------Distance from foundation____- --------Distance to,nearest lot c s � TyI u�, tii�of eachline - 1Nidth of trench �f ----------- p of iilternmaterial'' ' Depth of filter material_____/Z__.........Total length__________________ -Ca- ---_" h 1 �i t Seepage Pit: Distance,to nearest well_-.__ _____--:--.___Distance om f undation__�. �__.___..Distdnce to nearest lot Number of pits___.--`_._-----_.__Lining r Diameter - -3. y Depth !------------ Cesspool: V Distance trom nearest well________:----__-Distance from foundation___._._--______---.Lining material__.______________________________ El Size: DidQter--- -------------------- ❑ . ----- Deth _ Liquid d Cap a cE#Y gals._ ---------------- Privfromnearest well--------------______---"---_------___._----_._._D�stnce f om nearestbuildingt Distance,fosnearest lot line------- - , ------------------------------------ Remodeling and/or re�,airri g (describe):_________________ --------------- ----------------------------------------------------------- ---------------••--------------------------------------- -------------------•----------------- "—=-----------------------=--------------- - 1 ----------------------------- I ! t ------------------------------------- ---------------------------------------------------------- --------------------��-------------'- --•i ------------- ---------------------------------------- -------------- I hereby certify that I have pared This application and that the work will be done in accordance with San Joaquin County ordinances, S a� laws, nd rul ' a regulations of +he San Joaquin Local Health District. II , (Signed)-------- - --------- - >_ --------- v/�} ---------- - - - ---- ---- ---------------- --------------- f per and/or Contract y:-------- ` Ow d/o or) ------(Ti+le) (Plot plan, showing size of lot, location system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------- ------------- -------------------------------------------------------- 5- -- - _ -- DATE------._ --: ------------ REVIEWEDBY -------------'------------------------------------ -------- DATE------- •-------------------- ------------------- BUILDING PERMIT ISSUED---'r---•---------------- -- -------------------------- DATE. - ---------=----------------------------------- Alterations and/or recommendations:------ ---------•------------------•---------- --- ---------•--------------------------------------------------------------- -----•-•------------------ ------------------------------------------------- '--•----------- •----- ---------------------------------------------------------- ------------------------------ FINAL INSPECTION BY::.__: ^�' -- '' 411. - -------•---------------------------- -------•----- Date-- ii --- I SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street h 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California r E5-9-2M Revises 1-57 F,P Co. I i