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1\1� APPLICATION FOR $ANITA710N PERM17 `�� , Permit No. ____1�.�_.-__------ L (Complete in Duplicate) Issued ._-_9�1 __ -�Date Applica{ion is hereby made to the San Joaquin Local-Health District for a permit to construct and install the work herein described. This application,is made in compliance with County Ordinance No. 549. ; JOB ADDRESS AND OCATION `� �1$- _ ..� � � I ------------------------------------ --------- ----------------•- Phone Owner s Namei. �. _ .,w - Ad d ress -- 3l-6 ' - s z 16 Contractor's Name ' --------- ----- ---�- Phone Installation will serve: :Residence �'�p'artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 1 r • �'O o------------------------------ Number of living units: _�____ Number of bedrooms -- Number of baths _�_-_ Lot#size ._``arl!r.-_.__/ Water Supply: Publiclsysterri`�Com unity system ❑ 'Private ❑ Depth t� Water Table _ -Q ft. • 4 Character of soil to a depth of 3 feet: ..Sand..[].]Gravel ❑ 5andy Loam ❑. Clay Loarfi► ❑ Clay ❑ Adobe Hardpan ❑ i Previous Application Made: Yes ❑ No �Ne-w Construction:Yes ❑ No �r I TYPE OF INSTALLATION AND SPEC.IFICATIONS:� , ( a sewer is available within 200 feet.] Vii`. r }'. Tapk:. Distancefrom„nearesr Wella_______._ -__'Distance from foundation_____________ .MateriaL______________-___--_______________.._-____-___. No septic tankror cesspool permute ifi pu is se p ---------Liquid depth-------I--------- -----Capacity-------- - -------- allo.,of compartments- ------ -----------'--- Size os eld: Distanlce from nearestwell ...__.____. istancezfrom•foundation_-==__�-.---Distance to nearest lot line_______________ ,•Z Number of lines Length of each line -Width of trench p Type of filter material------- ----------------Depth of filter material--------.-------------Total length-------------------------------------- _,,, . Distance�to nearest lot line----- - Seepage it: Distance to nearest well��--Distaff c�f�rm found`tion__ #--, 3 'i �� . Number of pits.__:/--I-------1--Lining material____+ _--- ze: Diameter--------- -----------Depth______._______-_-- f Cesspool: Distance from nearest jell-________--.._-Distance from foundation._.._.:-__-° -----Lining material_____..__-------------------------- r .; ► 1"-------- --- ---------- 0. -Liq{d Capacity gals. ` . ,.�¢S�ze: Diameter:----=----=__--------------------- Depth = ; 4� t * I °.:Distance from neares+ building-------------------------------------- Privy:L Distance >rom. nearest well -- ---------------------------------- -- ' ❑ �_.. -"Distance to nearest lot lin __-� ,. � � -------------- ----------------•---=-- �'x = _ ------------------- ---- Remodeling and/or repairing (describe)-- -----------------------°--- --- .;:�»� '' _ -`--i' -------•------- ------------------------------------------------- ,� ��- -�'y -----------=-----------•----------- k� } -------- = -•------------------------------------------------------------ - . 4 .� ' . I hereby certify that l have•prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S laws;and rules and regulations of the San Joaquin Local Health'District,4 � a ., Tt lOwner and/or Contractor) '--- - -- -- -------------------------------------------- (Signed)- - - - ------------------------- ---- ----�- -------------- 4 - toBy:----_------=----- -- -- can be placed on reverse side}. (Plot plan, showing eof'lot, location of syste elation wells, buildings,.etc FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- --�' ---------------------------------------- DATE---- -- •--- --- ---- - --- REVIEWED BY f1. ----------------------- DATE_ . ` - ----`---- ------ ,� ---------------------------------------------- DATE----/------- ------------------------------ _T BUILDING PERMIT..ISSUED--='-•- ---=-=--I 40e-'---'----- ----- Alterations and/or recommendations:---'-----=------- --------- ---------- , r _____-. ____________________________________________ M1i ________________________________.._____ I } r ________ ____________________._____-_______-___._._-_-___..._._______.___. _ ____________-----------_-------------- FINAL INSPECTION-BY.-.�---='----------- �-=--------- ----- - ---"-' . . _�_ Date =_ ----- SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 432 Sycamore Street 814 North "C" Street !3o South American Street Trac California Stockton, California Lodi, California Manteca, California y, ES-9-2M ; Revised W-2100