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FOR OFFICE USE: ---------------------------------- - �� 9� ------------- - APPLICATION FOR SANITATION PERMIT Permit No. --..--•-----• ------- in Duplicate] 21-1161 ------------------------------------------ (Complete P bate 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. 549. E&E VIFVJ77f _ '_F - r JOB ADDRESS A LOCATION-�-� - Y"-r-r�rc - ) - ----rte ------ '� _• '-----•--------------- --------------- -- Phone---- Owner's Name ] ----- ---- •----- O /'l�st�[i-�+ . .0 l_ -•-•-------------------------•-•----------•------•---••---•---------•------------•- Address-- - -r�------ - ------}----- ---- ---------- Contractor`s Name--- ------- Phone. Other will serve: Residence 04 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _.l----- Number of bedrooms'1... Number of baths __/_.-- Lot size Water Supply: Public system ❑ Community system ❑ PrivateK Depth to Water Table I--- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeA Hardpan ❑ Previous Application Made: (If yes,date--------------------I NoX New C truction: Ye 'LNo [X FHA/VA: Yes ❑ NoX TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se�Tk-1 Distance from nearest well_________________Distance from foundation No. _.______- ____._.______. No. of compartments--------------------------Size--------------------------------Liquid depth----------------- --------Capacity---------------- DiDistance from nearest we€l.�y --Distance from founds ion____ .Q-. -Distance to nearest lo�t/li�� _ _______ t Number of lines-------, __-_ �_.______�_.r__Length of each lines__ --- .Width of trench-_-ei-7�.__---_______________ " Type of filter materialS_r '�fC---Depth of filter material----__�_g--____---Total length_______/_OC?______________________._ eepage Pit: Distance to nearest well---------------------- from foundation--------------------Distance to nearest lot line____-__.____--___ ❑ Number of pits.---------------------Lining material----------------------.Size: Diameter----------------- -----Depth---- ---------------------------- Cesspool: Distance from nearest well_________________Distance from foundation............... ....Lining material---------- .__.--------.__________-_. ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------.Liquid Capacity-_------------------------gals. Privy: Distance from nearest well----------------------------------------------- from nearest building-,_______---..____-_-______-------------- ❑ Distance to nearest lot line-------------------- ` -------------------------------------------------------- -t----------- ------------ Remo ling and/or repairin {d9scribe):__ - ---------------------------------------------------------- ----------------------------------------------------- ----------------------- - ------------ ----------------------------------------------------------•----------------------------------------------------------------------------------------------------------- I 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. � -� s -------------------(Owner and/or Contractor] (Signed)---- /� - 4r- _ Rwp" --------------------------_(Title)---------- --------------------------------- . (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-------------------------------------- ---------------------------------------------------------- DATE----------------------------------------------------------- REVIEWEDBY------------------------- ---------------------------------------------------------------------------------- --gyp DATE------ -__'_ - "a--------•------------ BUILDINGPERMIT ISSUED---------------------------------- �`'�''�r DATE----------------------------------------------------------- Alterations and/or recommendations---------------------- --------------------------------------------------•------------ ------------- --------------- --------------------------------- -------------------------------------------------------------------- -----I------------------------- FINAL INSPECTION BY:------ ---'------ -- ----- ------------ Date - r R-' ------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISEo a-59 3M 3•'63 F.P.Co. v