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FOR OFFI9.E VSE. "or r , ----- ---------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .._l. - _ (Complete in Duplicate) ..._�... a� ��.�.Y Date issued _-_.-__ ---•--7�-� ---�-�-.� _____________ ___-__ iThis'Permit Ez�ires l'Year From Date'Issued' , Application is hereby made to the San Joaquin Local Health Distritt for, permit to construct and install the work herein described. This application is made.in compliance with C�oun Ordinance.No. 549. „ JOB ADDRESS A L ATION ------------- ! -t - ---- _ _ Owners Name.... ' ------ �t�� ------------------------ - Phona------------------- .... /- -------------- , Addr00 ess :.. � �r�/}/ f�--•_.:.. .__ ,� !-'�-----"------ - 1�-4.--.:..-...-•-•--------------`----------------•--- ••--•----------------- _.r - a ____.___ f.,.u- � �[--.'- - _ f_________________�_____-____. k ________________..____.__.__._________ a ...___________......_._______ Contractor s- Name_:_ :.�"__ _ _ ___ Phone._! �f Installation will serve: Residence artmen House Commercial Trailer Court Motel . "Other ❑ �AP ❑ ❑ ❑ do Number of living units: _ __1�'_ Number"iof bedrooms __ Number of baths _: ._. Lot size .. -- �_�____-_-._--______________ Water Supply: Public.system 9;!Community`"system ❑ Private ❑ Depth to Water Table k Character of soil to a de th of 3 feet: Sad Gravel Sand Loam ,Clay Loam Clay Adobe arclpan P ❑. ❑ Y ❑ ,t , Y ❑ Y ❑ � L ❑ Previous Application Made: (If yes,da __ {- --__-.-..} No �� New Construction: Yes [ to ❑ FHA/VA: Yes No ❑ TYPE iOF INSTALLATION AND SPECIFICATIONS- (No PECIFICATIONS: r ` � Septic (Nokseptic tank Dor istance pomis permitted"if public sewer is available within 200 feet.) i p '=nearest wells_:"=.__-Distance �om foundaVn____/a:---___.Mat rial__ _ � _ _.___. No. of compartments--- ---- ..: � .�------Biz q p �----------- py. Q ._.._.. �� et�� -X_� _ Liquid depth--th__ .�--- Ca aeit Disposal Field: Distance frominearest well.__ _..._.Distance from foundati ,/..............Distance to-rrearestAot line_.161--------- N --.____. Number of lines------ - ----- -Length of each line---- ° ------------------Width of trend-----. .--------------------- Type of filter material_ �G�4 Depth of filter material_e. ..........Total length__ _ ---------------------------- e __________________________ " r p g ^� ares#;well___ "!"c'_______Distance fr m fo dation��,�_jis ante to nearest lot lir�t�.�.�_.. Ind See a e Pit: Number of pits.____�__�"_';„_,Lining material_/ jl :.Size: Diameter_ __-------______.Depth__�- ---_.�__________-__ Cesspool: Distance fromnearest "rvel______________'DDistance from foundation----_------_--i-_-_ Lining Capacitytril- --------------------------------- p g ❑ '__ p q ----------------------------gals. Sze: Drame#er---------- ------ ---- 'Depth -------- Privy:' Distance tom ratelot line l .w__. _} � -Distance--fromTne-arest-building_________________________;_______._--.._. Distance ❑ -- I' - i Remodeling and/or repairing (describe}:----- ...........--••-----:--• ------------•-•------- r -----------------------------------------------•----_.---.-------•-------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - I hereby certify that-I have prepared this application-and that the work will be done in accordance wi#h San Joaquin County e ordinances, State laws, and rules and regulkf;ons of the San Joaquin Local Health District. 1 (Signed)---------------------- __774�__ ell • __ — •-•--------------------- -Y:W20UFV9d71tr-Contractor) By� ----------------------'-- ... (Ti#le) � "'....._.... - - - (Plot plan, showing size of lot, location system in relation to wells, buildings, etc., can be placed on reverse side). i FCRi EPARTMENT USE ONLY f ----- ----------------------------------- -------------------------------------- DATE------ -, re”-f 3 REVII WEQI BY_ON ACCEPTED BY �; ----------- - DATE = ' BUILDING PERMIT ISSUED............... •------------------------=---------------------------=-------- ------ DATE.-------•--------------------- - - --------------------------- Alterations ---------------------- Alterations and/or recommendations------------------------ ----------•-- --------_......... ---------------------------•-•----- i r ---------------------------------------------------------i-----•-------------------------------------------------------------=------------ •------•--•-•---..........-.------------------------- -._...--•----•--•--------•- ---------------------------------•------------------------------------------ ---------•-----------------------=----------------------•---------------------------- --------•-•----------------------------------------------- I ....................._-----_-------------________________i'_________-__....____....._________._.________---------_---------------------------------------------------------------------------------------.--------------------- .Y 11 FINAL INSPECTION BY:..__ �. �. Date --'.� -�- --- ----- --------------- ------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT X30 South American Street E 300 West Oak Street ; 'al 124•Sycomore.S6eet ` 205 West 9th Street Stockton,California i Lodi,California Manteca,California Tracy,California BED 6-59 F.FX0,2. 6•64