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FOR OFF-ICE US5,: --------------------------------------- ------------------------- ---------------------------- APPLICATION F0_ _ R_ SANITATION PERMIT Permit No. ........ ------------ ---------------------------- 'plicate) ' ii (Complete in Du Date Issued ------------------ This Permit Expires I Year From Date Issued x Application is hereby made oto th'I San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance I with County Ordinance No. 549. 1L (4j9tqj 51 De JOB ADDRESS AND LOCATION-------(aF4r ............ NTRA` --- ------PLA e. J-'-UV.......or..... Owner's Name- ------ ------C-6----------- ---------- Phon a-----;M------------------------------ Address......... - -------- .................. ..... Contractor's Name------OWIV��_t-------------------------------- Phone--•-I[....1[i .....r..-.._.._ - . il i�---------- Installation will serve: Residence [] Apartment House E] Commercial E] Trailer [rm otel ❑ Other E] Number of living units: Number of bedrooms ---/___ Number of baths --- Lot size ---19- 4-R. is----------------------- Wafer Supply: Public system❑El 4 Cotmunity system E] Private DR-_`Depfh to Water Table/e ff. 1 Character of soil to a depth oi 31feef: Sand Gravel 1-71 Sandy Loam E] Clay Loam E] Clay E] Ado Hardpan E] Previous Application Made: (if re's,date-------- j No jjj�New Construction, Yes �No E] FHA/V4 Yes ❑ No, TYPE OF INSTALLATION ANDZPECIFICATIONSt (No septictfe u ic sewer- tank or 'T" is pvailable within.200 feet.) Septi T k: Distance from nearest we -----Distance from foundafion___/Z7---- - .Mate rial---- No. of compartments-. --------I....Size--3.X_%_>.<---S---Liq.id dep.fh_.__,4_�----------------Capacity---- Ditpo;al Fie�d: Distance from neare-sf wefl�_.57D------Distance from founclatic' n----AQ --------DistInce to nearest lot linea. _,� Number of lines----------t------I----------------Length of each line------��o --Width of trench---------- %A Type of flifer material---ROCK---Depth of fllter.mater�al--- ----Total length-----------:�------------15D---------- Seepage Pit:. Dls;aZte. to nearest well----------------------Distance from foundation------------------- Distance to nearest lot line----------------- El Number'of,#ts-----------------------Lining material---------- ------------Size: Diameter Distance to Depth--'-------------------------------� Cesspool: -.1! 1 Distance 4i-6rh nearest well-----------------Distance from founclation--_---------.-_.Lining materi6f, ----------- 7 it ,r Size: Diameter_�---- -------------------------- ----Depth----------------------------------------------------Liquid Cap6cP----------------- ----------gals. Privy: Distance from nearest well'------------------ ---------------------------Distance-f ro"FNnea rest buildirig------------------------------------------ El Distance to nearest lot line--------------------------------- - ------------------------------I!,so . . ---------- Remodeling and/or repairing (describe)----------- ------•IS ------------ &-------------------------•------------------------ ----------------I-------------------------------------------------------------------------e5iRPO----- ---------- ------------------------- f ---------- ---------------------------------------------------------------------------------------------------------------------------------------------------*-------------------- II -------------------- -------------I----------- --------------------t----------------I-------- ---------------------- --------------4---------------------- --------*---------------------- -------------- ---- --------- I gere6y c-erfify fhz�til ha prepared this application and that the work will be doirein-,accordance wAitVSa'6' Joaquin County ordinances,-.Sf ate Taws .and rules and regulafions,,bf the San Joaquin Local Health Diifr'icf. 5i ned (23 ------------------------- - �' r - '!� ir Contractor) -------- - ---------- ---1--------------------------------------------------- -------------(Owner and/o r) py:---------------------------------------------------------------------------------------------------------------- ------------t---(Title)-------------------------------- ----- - ---------------- (Plot-plaln,-showing-size,*f..Iot,-location-of-system in�relafion_fo wells,-6uildings, etc.,- cant6f( 4laced-on-reverse-side),;.- .�.i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_----- -- ------------------------------------ ....... ----------------- DATE--- REVIEWEDBY--------------------------- ---- ------------ ------------ --------•----------------------------------------------------------- DATE----------- ------------------- ---------- UIPERMIT ISSUED---------------------------------- ----------- ----------- : .. _T------------------ Alterations and/or-recomm-e7!n�daf-io-ns—:_t- ----------- ------------------------------•--------------------------------- ---------- ------- -----------------II ---------------------------- ----------I——-----_----------------- ------ ---------------------------------------------- -------------------------------------- ---------------------------- ---------------- ---- ------------------------- ----------------------- ------------------------------- - -- -------- -------- --- -------- ------------------------------ -------------- ----------- --------- --------- ------------------- ------ -------------------------- ----- - - -- -- ------------ ----- - -------------------- ---------------------------------------- --------- ---------- FINAL INSPECTION BY: ------- Date- - - --------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Maxelton Ave, 300 West Oak Street 124 Sycamore Street 205 Wes 1 t I 91h Street Stockton,California Lodi,California Manteca,CaliforniaTracy,C California fI ES 9 REVISED 5-59 3M 3`63 F.P.00.