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F9ROFFICE USE II I ----------------------f i z4 !4 [ Permit No. Z, -17 -_.9 ----------- ---- - -_-_J__------------ ---- APPLICATION SANITATION PERMIT y--�� ----- -- - -------- (Complete in Duplicate) --------- ------------------ -- ------ - - - Date Issued &7 4-----•l- --------------------------------------- ------------------ �0' This Permit Expires l Year From Date Issued Application 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 LOCATION---I---- �------ -� � -------��-------------------------- ,..... ----------------- Owner's Name...................�4 -�-----------5)---, ` '/�•.--------------------------- ---_ Phone........---•-•---------------- Address................... -`�_ `n. [ �l.e{............/--r---A............................. _--------- Contractor's Name--------------- -� 'L'�--------------•------------- -----•--- Phone............................. Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other aj� Number of living units: Number of bedrooms -4---- Number of baths ... Lot size ---------5-d.X... .DU----------=---------- Water Supply: Public system"K Community system ❑ Private ❑ Depth to Water Table -------- ft.11 f Character of soil to a depth of 3 fast: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam.❑ Clay ❑ Adobe)q Hardpan ❑ Previous Application Made: (if yes)l ate____________________) 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 nL arest well,'�tX-Distance from foundation-__/,0�___.Material..... .�61 ...i ❑ P �.-------- Size _ :.-. Liquid depth-------I-------------- .._.��- No. of com artments_._..__._ __ C Disposal Field: Distance from nearest well�t ._Distance from foundation__)P .....Distance to nearest lot Iine...:S:_':........ ❑ Number of lines:........... _____ ____________ ength of each line........ ._______:___.Width of french---.tel..._.................. Type of filter material Xi_A�Depth of filter material_____�� _______Total length._._..- ........1.................. s•u-. 11 -r- 7- Distance �:- to nearest well__ 4J?-<L-Distance from faun ation___._/1V__._..._..Ptance to nearest lot ...___.- ❑ Number of pits-1------/------------Lining materials / Size: Diameter__(A._--k-ZY___Depth....../-.3- ________-.._ Il Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material----------- .__----------------------- ❑ Size: Diameter-A-----------------------------------Depth.---------------------------------------------------Liquid Capacity---------------------------- V\ Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_______________-___•-_-------__-_________- ❑ Distance to nearest lot line------------------------------------------------------------------------------------------------------------------------------------••------- Remodeling and/or repairing (describe,):__ ..-4.._ I� ... . -•-•----- ----------------------------------------------------------•-- •----------- --------------------------••- i--------_-_--.....-----------------------• ......._ —..__._._.....I................................................. ........................------- --------------------------------------.. .-------- -- 9 I hereby certif hat I have prepared this application and aha+ the work will be done in accordance with San Joaquin County ordinances, State ws, and rules and regulati of the San Joaquin Local Health District. gyp. � "" Si ned Owner and/or Contractor By:------------------------------------------- -- ----------------=-----------------------------`--------..............(Title)----------------------------------------.._..---- -------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). ` It DERARWENT USE ONLY F APPLICATION ACCEPTED BY_�._-__�M- ` � ,-- - -------- DATE---------I1 = REVIEWED BY----------------------------- ------ --------------------------------------------------------------------------- DATE........................... ------------------- •-•--•-------- BUILDING PERMIT ISSUED---- -`------------•------------------------------------------------------------------------- DATE--------------------------------------------------....... ..._ Alterations and/or recom ndationsz___-/ _ -___-_ ...... ----- ---- ----- --------=1 �_ -�-Q:1� ------ -- ---------------------------------------------------- --------------------•----------------- ----------------------- Il ...__.. --------- ----- FINAL INSPECTION :. / ------- Date------------- ��.`-��-d---:��----- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B-59 21A 6-61 ATLAS 4 !