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FOR OFFICE USE: / :f 1 Permit N + APPLICATION FOR SANITATION PERMIT � = � '-------'--'----------------- --- -' ,%.�---_ {Complete in Duplicate) "Dare Issued -------------------------------------- __V:,3.0__.___ This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health Pisfrict for a permit t construct and install the w rk herein descried. This application is made in compliance with County Ordinanc ljo. 49. JOB ADDRESS AND LOCATION_ _!--lam-I- / ---r--- - Owner's Name------ -5?�� ------ -----•------------------------ ----- ------- Phone.'7" Address _. .C17 - ,k .... ------ Y --- ' Contractor's Namd �r...__. "� --- ----- - Phone_._ Installation will serve: 'Residence Apartment e ❑ Commercial ❑ Trailer CMotel �ther ❑ Number of living units: N tuber of bedrooms Number of baths----------Lot size --Q-67---- ------ Water Supply: Public system Community.system ❑ Private ❑ Depth to Water Table .,ft. a Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑, Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ a Previous Application Made: (If yes,date....... Nb.;❑ New Construction: Yes ❑ NoHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: No septic tank or cesspool permitted if public sewer is available within 200 feet.) XDTC,Iati��isfance from nearest well-:--------------- from foundation--------------------Material ________________________________________________ rte' o. of compartments--- ---------Size--------------------------------Liquid depth--------------------------Capacity---------------------- _ o Distance from neare t well4A0xk istance from foundation__�_.0-_ .-.Distance to nearest lot�ine�� Number of lines__,_i ------------------___Length of each line__---Q__----------Width of trench ._-- -oo��_______ Type.of filter material_ '. ___ __Depth of filter material____-__� �o__-__ otal length___ __ �� �� ag �t: Distance to nearest well ._ _ _________ - Distance om foundation__ __Q. ___.Distance to nearest lot line----- _._ O dNumber of pits____ .____._________Lining mafierial__ _ Size: Diameter__._ �f___.Depth_- ______________ `esspool: Distance fic'm nearest well----------_------Distance from ouncla+ion--------___:_.___-_.Lining materia_______________-----___._________-__ [] Size: Diameter ----------------------------------Depth------ :------ Liquid Capacity gals_ a� `- -Distance from nearest building Privy: Distance.from,nearest well------------------- -_--------------- - - - - 9-- ------------------------- ---'-' ❑ Distance to nearest lot line-- ------------------ -------------------------------------------------------- -------------------------------------------------------- r' ------------------- Remodeling and/or repairing (describe):-- -------- -_------------------------------------------- ------------------------------•-------------- ----- ------------------______ ________________ ______________ ________________ _ _______---------________________.___________T___________-___________________----____ w 11��__mac. "1e="—� I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County # ordinances, t ws, and ru and regulations the S �n Local Health District. i ��, (Signe --------------- r ontract or) _ By:---------------------------------------------------------------------------------------- �. can tle]---------- ---------------- ----------- -------- (Plot ------ ' (Plot plan, showing size of lot, location of system in relation to Is, buildings, ee placed on reverse side). FOR DEPARTMENT USE ONLY // Gam"' ------------------------------- DATE------`c ------ -- -`� ---------------- APPLICATION ACCEPTED BY--------- Z/._------- REVlEWEDBY------------------------------------- ------------- ----------------------- -------------------------------------- DATE-------•---------------------------------------------------- r BUILDINGPERMIT ISSUED-----------------------------------------'--------------------.--------------------------------------- DATE--------------------------'---------------------------------- Alterations and or re c mm ndation�___________ -----_ ___ , - = �, `- --D ..--------------------- ------------ - -------------------- -- ------- --- -------- ------------------------------------------------------- ------ ----- ----- -------- _ ._ ---- -- -'---- -------------- --------- --- ---------------- ----------------------------' -- ---------------01 ' �r //�� p - FINAL INSPECTION BY------.-C...T ------------------------ Date........ / --'-- ------------------------------ --------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Harelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8.59 3M 3-'63 F.P.CG. /y