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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ----------------------------------------------------•--- . S._.� (Complete in Duplicate) Date Issued --------------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Heal}h District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 54� qq // - JOS ADDRESS AND LOC TION.........1__1___�.1__________ __ _ __ •{ --- ---- Phone.. .- ,-�----y Owner's Name._.. -- ------- ; ----------------------- `` = _ . 4 Address-----------------•-------------------- _ ----•- -- ----- -------------------------------- ---•-----------------••---------- Contractor's Name_.402.1- t_-.6�.. Phone._—�c_----�--. Installation will serve: Residence ❑ Apartment Houser E] Commercial ❑ Trailer Court [] Motel ❑ Other Number of living units:-------- Number of bedrooms -------- Number of baths -------- Lot size ------------------------------------------------------=------ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe, ] Hardpan ❑ Previous Application Made:; (If yes,date------------------- -I No ❑ New Construction: Yes ❑ No ❑ 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 foundation---------------------Mater.ial-___:____--.-.-.-_-_---____--_-_-_--------_----- � ? Oo.,of compartments - ------Size---------------•----- ---Liquid depth------------------------Capacity = ❑,� p : , a Disposal Field..?�3.Aisfance from nearest well-----------------Distance from foundation____.._.___________.Distance to nearest lot line___________._.__. ❑� _ , Number of lines-----------------------------------Length of each line-------- ------------Width of french-----• --------------------------- - '� Type of filter material-------------------------Depth of filter material___,7:.-----------:-7-Total -length----_-----------_:_-----_---____-_-_------ ' Seepage Pit: Distance to nearest well----------------------Distance from foundation_-__:_._.............Distance to nearest lot line-_-_------------. t; Number of pits.------`--------------Lining material---------------_-------Size: Diam ter-----------------------Depth---------------------..---------- Cesspool: Distance from nearest well-----------------Distance from foundation----------1---------Lining material_--._--_.----_.-_---_-----__--_------. ❑ Size: Diameter--------=----------------------------Depth----------------------------------------------- ---Liquid:;Capacity------------•------------•--gals. - x Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---------------.----------------------.--- ❑ Distance to nearest lot line--------------------------------- --------------------------------------------------------------------------------------------------------- 4 7 f \ r.>3 airin( ------ --`-- ----_ -------------------------------------------------- ¢. ------ ------------------------- . Vii'" ; ------------------•------------------------------•---------------•-------------------------------- Ihereby certify that I have prepared_fhis application and +hat the work will be- done in accordance with San Joaquin County t' ordinances, State laws, and rules and regulations of the.San Joaquin Local Health District. (Sit . g -----------------(Owner and/or Contractor) I J By:------------------------------•--------------------~--'=f-- --------------------------------•-------------------------------------(Title)---------------------------- ---------- - ---------------- (Plot plan, showing size of lot, location of sy� em in relation to wells, buildings, efc., can be placed on reverse side). FOR DEPARTMENT USE ONLY -, APPLICATION ACCEPTED-BY-_--- _.c�f '� ' ------------------- DATE-- `1_7—k _�--------------------- REVIEWEDBY_-------------------------------:-- __ ----------------------=------..--.-•-- ------------ DATE---------------_-=----------=------•----------------------- BUILDINGrPERMIT ISSUED x - ------------------------------------ D ..._. - Alterations'and/o reco menti tions:. � .-, i ------. -- ------- - �` --- ---- - - ---=-'- --------- ----- - - ------------ r a - - �--- 4 ------ ----- - :. s FINAL INSPECTION BY:... :-- 4 - l-2.- ,T �.. Date-,/j 714f_6 0-------------------------------•------- ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,•California Lodi,California Manteca,California Tracy,California [19•9 REVISED 6.84 f.P.CO.2M 6.60