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FOR OFFICE USF: ----------'•----------------------------- ------------- APPLICATION FOR SANITATION PERMIT Permit No. ---------------------------------------- --------------- (Complete in Duplicate) jA This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Healfh District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. I [ JOB ADDRESS AND LOCATIONS--{---J.�a --------- :__ .f s�l1�1.-------�I____4---•---------_ "! Nr 1c} .=...................... Owner's Name_ ,.,.r ------------------------- ��--------- Phone---------�---------------------•--- Address----------•-• _-5-------------X= .r: i.)i�Q.!..�f. Contractor's Name__ - .9.NT CP...... . C. -5. � _I C- .. --- Phone-------- ........................ Installation will serve: Residence [� Apartment House ❑ Commercial ❑ Trailer Court 0 Motel ❑ Other ❑ Number of living units: /-____ Number of bedroomsNumber of baths ..)-. Lot size �--------------------- Water Supply: Public system Community system ❑ Private ❑ Depth Water Table( _ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel [3 Sandy Loam R3 Clay Loam [—] Clay C-] Adoben Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes o [ ; FHA/VA: Yes ❑ No 21 ' 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 al______-- ............................. TI C� p ------•-------Liquid depth---F es".-�"'----- Ca aei No. of tom artments---------------------------Size.-•-------------- - � - P �tY----------------------- Disposal ------..._............ P ' foundation...,.—..,.........Distance to nearest lo't line...... ........ Dis osal Field: Distance from nearest weIL��N�_Distance from Number of lines.._.._____._.___ _ Length of each line-------- r. Width of trench_______ -_-______-___ Type of filter material..___ QC T Depth of filter material___ _ _ _____ Total 1[gth_._.... .....__ --______1........... Seepage Pit: Distance to nearest well--------_-------------Distance from foundation__..................Distance to nearest lot,line................. 1 ❑ Number of pits---------------=------Lining material------------------------Size: Diameter__-JA__.._... .- Depth-----I ------------------ Cesspool: Distance from nearest well_________________Distance from foundation___---______._.____.L.ning material .. ----------.-_-_____._____..._....... El Size. Diameter. Depth -----•--------- -- --------------(--•--�-----_Liquid,Capocity....--;y-.................gals. Privy: Distance from nearest well________________________________________________Distance,from nearest building_________--_-__-__--__-______.__._______- ❑. Distance to nearest lot line--------------------------I-------------------------------------•--- Remodeling and/or repairing Idescribe)------------------------------------------------................. -------------------------------------••-- ----------•---•-----•-------------------------•------•------......----•--------------------------------------------------------------------------------------------------------.................................... •-------------------••------__----------•----•------------ ..............................----- _=-= ==_ =-_•_._..-_.:: -------- ----------------------------------------•--- --------------•---------------- k I hereby certify that I have prepared this application and that the work will be done in accordant® with San Joaquin County oiainences, Sta a laws, and rules and egsuL' nf �San,Jjoaquin Local Health District. (Signed).---/- ...... = -_ (Owner end/or Contractor) BY: q.". - ieio......••-------• .==-=; - - (Ti( T --.. ......................... (Plot plan, showing size. of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). k t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_. ._ _' _ , ------------- DATE _ _ - - - --_-.--•.-,----• REVIEWEDBY-----------------------------------------------------------------•-------------------------------------------------- DATE- -------------•---------••----------------------••--•--•- BUILDINGPERMIT ISSUED_-------------------------------------------------------------------------------------------------- DATE--------------------.--_---------•-------------------_------. Alterationsand/or recommendations:------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ --------------------------------------- ----------------------------------------- -- ,e // FINAL INSPECTI ---r-U;�� Date.... 7-,//:7--61 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Srrgt ]2q Sycamore Street 205 West 9!h Street Stockton,California Lodi,California Manteca,California Tracy,California (;w/ E8 9 REVISED 6.59 EM 6=61 AYLAS