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FOR OFFICE �15E: � ' � �" f22" ------ �------ i v I t9"�J --- --------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ` - -- ---------------------------------- ------------------- (Complete in Duplicate) 6 ------------------______--------------_---_----__-------- -This Per"mit Expires 1 Year From Date Issued Date Issued -crr? --.-.........0 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------ '--, ��_a/�_�GyG =------------------- ----------------------------------------------------------••------•--------- Owner's Name._ ? 128?-� -. f?r1.�P/7_G�E�� --------•------------ ----- Phone._._..-----•-•------------------•--- t t - ----------------------------------------- - - Address-------- :. f- 1z1--. (t�C-------- s_ ct� fr --------------------------------------••- •----- ------------------------- 'fes.., Contractor's Name --------•-•--•----------------•------•-•----__ Phone,t,ZV..-,Z-7-054Z - Installation will serve: Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __�___ Numbei of bedrooms _yNumber. f baths _ .._. Lot size ___-c 8_A_._ _.f.o4<. ..................... Water Supply: Public system%,Cornmunity system ❑ -Private ❑ Depth to Water Table(GlD__ ft. Character of soil to a depth of 3 feet: ,Sand ❑ Gravel ❑ Sandy Loam ❑ Clay .Loam❑ Clay ❑ Adobe fi�, Hardpan ❑ F Previous Application Made: (If yes,date---------------._-_-_} No ❑ New Construction: Yes ❑ No 14,PHA/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_tA_6_AR_,bistance from fo ndation.__it�?--.-------Material------ _ ____-______ _ _ No, of compartments,_° _________________5ize_.' _�-___Liquid depth____, '!___-___--Capacity___ Q--___- Disposal Field: Distance from nearest well-= Distance from foundation------ --- Distance to nearest lot hmaterial i Y _ length li�ne_ ________________ of ubs .. fines - , Length of hl - ---------- htrench. 7t______-_______LTYPeoffiltematerial_______ Depth offlte: ma#erial-�� --- ---Total ien9th_ ---'�� Seepage Pit: Distance to nearest well __________------------Distance'from_foundation__.._______._._.___.Distance to nearest lot line_________________ ❑ Number of pits------- "_�__�__YLining` materialt_--_ p �( _.-___--------Size: Diameter------------•----------.De th-----------------••----•--------- Cesspool: Distance from nearest well_______._-__ '..-Distance from #oundation____________________fining material__._____._..__._____.__....._________ ❑ Size: Diameter. :_------ ------------------Depth-------=--------`: --------------------------------Liquid Capacity----------------------------gals . Privy: Distance from nearest well-_-_--�_________ ______________F_________`=__Dis#ante from nearest-building-__._-.______________---_____.____._____. , ❑ Distance to nearest lot line--•.------------------------------°------------------------------------- ----•-----------------------------•----------------------------------- Remodel' and or re airin describe :_.______-____ ._ __ i__________________ _______ __ / 1} 9 I ) ----------------- == = - -- - - -- -- - C f ------------------ = 6z F - ----------- •-•--------•--------------•-------------------------------- -------------------------------------------------------- --------------------------------•-------------------•------------•--------•---------------------------- --••------ 1 hereby certify that I have prepared this application and That the work will be done in accordance with San Joaquin County I ordinances, e I ws,-and rules and reg ions of the San Joaquin ocal Health District. t (Signe( )- - ---- -- ----- ------------------ ierrami�mr Contractor) (Plot plan, showing size of lot, location of system in ation to wells, b 'dings, etc., can be placed on reverse side). 121 DEPART ENT USE ONLY 246 APPLICATION 'ACCEPTED BY `'a `----- -= --------------=----" DATE-2 -` l REVIEWEDBY------------------------------------------- - '$ --------------------------- ----------------- ------ DATE--------------------------------- BUILDING PERMIT ISSUED--------------------------- ------•------------------ ------- ------------------ DATE------------------------------ Alterations and/or recommendations:-_-__________ -----------------— X -------•-•------------------------------ -------------—------------------------- ------ = -------------------------------------- ---- ------ --- -----------------------------------------------------------------------------------------------•---------------------------------•------------------------------------------ ------------•--•--•-•----------- FINAL INSPECTION BY:-- -_-- ------------------- Date___.. __ _ 'G• --------------- ----•-- -------------------------- 7 t SAN JOAQUIN LOCAL HEALTH DISTRICT '4 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California a Ea-9 REV18ED 8-59 r.P.co•,2M 6.60