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a FOR OFFi E SE: / 1/ G --_ --� _- --------- �(x_ ,�--_- r APPLICATION FOR SANITATION PERMIT Permit No. �.. ............. ' (Complete in Duplicate} 1 ., DtiA ate Issued ----` This Permit Expires 1 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. 5.49. JOB ADDRESS AND LOCATION...._._�:_Z �_'1__ _ --,------ ' Owner's Name - !. ------------------------------•---------- - .. Phone. 3 F Address----------------6------ - -------- = :... Contractor's Name---- - ._-_----___-• --let- ------__ �r�-�1,. > �- .u. t e ��'""c'......... Phone...- -r - •------Y Installation will serve: Residence [1E�'_Apartment House ❑ `Commercial ❑ Trailer Court ❑ Motel ❑. Other ❑ Number of living units: ___1___ Number of bedrooms : Number of baths --- Lot size -------��-1?._._ _f�-G�__ __� . Water Supply: Public •system �ommunity'system ❑ �Private 0 Depth to Water Table-; 'ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ lay ❑-•-•Adobe f Hardpan Previous Application Made: (If yes,date--------_-------_.) No New. Construction: Yes [ o ❑ PHA/VA: Yes ❑ No Er TYPE OF INSTALLATION AND SPECIFICATIONS: I ; t(No septic tank or cesspool permitted if.public sewer is available within 200 feet.) Septic Distance from nearest well------------- --Distance from foundation-------------------.Material------------------------------------------------- No. of compartments-------------------•-_-...Size...................._.......:...Liquid depth.-..-.--------------------Capacity---------_-_-_------.-- Disposal Fi Id: Distance from nearest well-----------------Distance.from foundation------------.-------Distance to nearest lot line__...__..._______ Number of lines-----------------------------------Length of each line-------.---------------------.Width of trench------------------------------------ Type of filter material-------------------------Depth of filter material----.---------f__ Total length------------------------------------------ Seepage Pit: Distance to nearest well---- Distance frNn foundation----4A----------- 's ice to nearest lotAP _________________ QI, Number of pits------1--------------Lining material-----Ef-C�---Size: Diarheter__:_ 4_--...___Depth_7--------17??-! --- Cesspool: Distance from nearest well-----------------Distance from foundation---------------------Lining material----------------_---------- __________ Size: Diameter----------------------------------- Depth ---Li incl Capacity ❑ p q p tY ---•------- gals. t' Privy: Distance from nearest well-------------------------------------------------Distance from nearest building ❑ Distance to nearest lot lin;---------_--------- Re deiing a d/or repair g (describ }: - ---• ------- -_ .1 --- _ _. _ `� ------- -- � f1---- ---- � - ------ --- ' { ereby cer+if that I have pre red this appli ion and that�he work will be done in accordance with San Joaquin County ordinances, State aws, and rules an regulations o the San Joaquin Local Health District. y (Signed) - -s------- = t ~----------------------' ------- �'�` Owner and/or Contractor) �J �Y- --------------- --------•-•-- ------------------(Title)--- - 1__... .................. -- (Plot plan, showing size of lot, ocation of system in relation to wells, buildings, etc., can be placed on reverse de). r < OR DEPARTMENT SE ONLY ry APPLICATION ACCEPTED BY------- ---- -_- -- -- r f-`moi------•---- DATE------ REVIEWEDBY_------ ------ --------------------------------------------------------- _-------------- DATE--------------------- BUILDING PERMIT ISSUED_-- ••--------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recd mendations__ _____ _ _ _ -----------�--- ..... ................ _ ---I----------------- ------- w -- •----------------------------- ------------------------------------------------------------•----------•-•----------------------------------------------------------- ------------ -----------FINAL INSPECTION BY: -------------------------- Dater_^ ?------------------------------ SAN - SAN T JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9+h 5freaf ? i Stockton,California / Lodi,California Manteca,California Tracy,California E6.9 REyl66o 6-61 r•.r..Co.2m 6.60 A