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' FOR OFFICE USI ______________________________________ __________________ APPLICATION FOR SANITATION PERMIT Permit No. __---...--__.........._. ------------ ------------ ------------------------------ {Complete in Duplicate) Date Issued ..I_-[.(-(,� ----------------------------------------------------- --- is 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. 549. JOB ADDRESS AND LOCATION----------------2---72 = 5 Owner's Name----------••---•------. --------------s - -------------------------------------- Phone .. Address------------------------ ............... ----- a o� o � Contractor's Name...... c} .._..-- —%-- Phone.............----•---------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___Number of bedrooms ._Y__. Number of baths .. Lot size __..____--- _ ar....1..... . ...... Water Supply: Public system B--Community system ❑ Private ❑ Depth To Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam �Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date-- -----------------) No E�--New Construction: Yes ❑ No Q---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: Diyfanceoo crest well-----------------Distance from foundation--------------------Material______.-___-_-__-•_--_______-..-.._____---------. d rtAk/`1;r0- �mp efits--------------------------Size........-----------------------Liquid depth--------------------------Capacity-------------._........ � Disposal J/j�+'�ante from nearest well____-- ._Distance from foundation......3...v....Distance to nearest lot line........—i V� ao1mber of lines-----------------f______________Length of each line__________ ---Q----------Width of trench-_-_-_______�__.______ TYPe of filter material_ ______�j-""'----Total length............ .__ De th of flter material See Pit: Distance to nearest well---- ---------Distance from foundation---- --j_-4?------Distance to nearest lot line-------+:.Sr-_ Number of pits-------f_________-Lining material_ D-t ____Size: Diameter--g.?__....___Depth------- ............... Cesspool: Distance from nearest well-----------------Distance from foundation-_------------------Lining material------------------------------------- 0 Size: Diameter--------•-----------------------------Depth--•-------------------------------------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building____________________-----•--___----____.-. ❑ Distance to nearest lot line------------------------------------------------------------------------------------------------------••-•--•-------------------------------- Re odeling and/oro repairing (des ribe):----------�X-S-•:____- ------- -- �r-� aR._ -•------ ----- ------------------------- ---------- -- -. .4----------- ,---�¢' ......__..__-'ar7.7t� � '..--- - ---- r l/ S- ___E________ __-._.__�C_ __ �se4lJ_._ ___ __ !f..eL.►t�,� ... _...__ __ _ ....... _ _ _ ________ _______________ --- ------------ ____ - ---------------�-----�---�----------------------------•-------------------_----------- - hereby certify that I have prepared this application"and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed}. ._.. s {Owner end/or Contractor) ---------------------------------- -----(Title)--------- ------------------------------- - -- -- (Plot plan, showing size of lot. Iota n of system in relation to wells, buildings, etc., can be placed on reverse side). I F DEPARTMENT USE:ONLY APPLICATION ACCEPTED BY-------- __ __ __ --f`--- - - - ---------=-------------------------------------- DATE----------�- •-✓!_ •--------'-'--------------- { REVIEWEDBY --•----------------------------- ---- ------ DATE- ------------ •--•-----------•-- BUILDINGPERMIT ISSUED------------------ ..........----------------------------------,-------------------------------------- DATE----------------------•--•-- •----......------------------ Alterations a /or r commen ations:.--t--------------------------------------- - ---------------------- --- - f �A = � l�-� Q �f f1.----�/-C..:... ..��------------------------ ---------•-................. ....... ----....---•-- •—f 0 -- -------- ------46--- ✓ ----- — � a - / ..- -------------- -- - — ` �.te •�,..-�cc• . t r� , FINAL INSPECTION BY:. S ^•---- Date !��--' - ----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Strut 300 West Oak Street 124 Sycamore Strut 205 Wed 9th Street Stockton,California Lodi,California Manteca,California Tracy,California Es 9 REVISED S-99 2M 5-62 ATLAS