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FOR OFF C ,�JSE: - ---------------- ---------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ....�..-- .._-_... v --------------------------------------------------------- (Complete in Duplicate) r This Permit Expires 1 Year From Date Issued 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. l JOB ADDRESS AND LOCATI N---_ -c------_-- _ r ---- ----------- ------- --------��--------- Owner's Name------------ ..---- --------..- -- --- Cs> � Phone .__! ; _---- ---------•------------------------•-------------------------------- •------ Address--------------------------- -----� ---------------------------------------------------------•-------- Con+ractors°;Named -•- -- or -� -------------------------------------------------------------•------ Phone.. .I------------------ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ umber of living units: __t._-_ Number'of bedrooms _2_— Number of baths _ ._. Lot size ----- 7 --------------- _ _ _ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table 3=-rft. 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 New Construction: Yes 0a1No,❑'= FHA/VA:Yes ❑, No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) y Septic Tank: Distance from nearest well__i6T------Distance fronn founIption___ Material---- --.__-___________- No. of compartments------`------------Size:---- {L` ._ __:__.Liquid depth_____,f5----------------Capacity__Ielu�. 7 Disposal R Id: Distance from nearest well. -_..-.Distance from foundation,,-/ __:____Distance to nearest lot line----4---------- 'I Number of lines_____________ _____,_--___ ____ Length of each line,_ 4_4 0W.idth of trench _ =�_ _ -.Type of filter maters _ }Depth of filter material_____-_-______Total` length_____________________ _5...___..__._ See a e Pit: ' Distance to nearest well-5- p g ___7 __Dista om tion___��__ .-_pis�ance to nearest lot amine____ _____.__ ® Number of pits----./--------------Lining mate ia1 �R i e: Diam6for.Ak(P_ .._____--_--Depth--ll'-------._-------___ Cesspool: Distance from nearest well----------------- r anon- _---__- _'!.__..Lining material-------------------------------------- El Size: Diameter--------------------------------------Depth------------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from n crest building_------------_'_._.-..-_.._.__---_--__---_. ❑ i -- Distance to nearest lot line-------�-�---�------------------------------------*,��„�� :�-�';-----------------------------•---------------------{ ---------- Remodeling._and/or repairing {descrihel-------- --------------------=------------- ••---------------- :- -•------------•-•-------------------------•------•-••-------•-------•--------------------------------------------------------------- ---------------------------•---•--•-••-•--•—----------=------------- 31 "k r " =----------•-•---•-••----------•---------•----------------------•-------------- •--------- ------- -------------------------------------------------------- ----------------------------------------------- .------------------------•-•--------------------------------- I hereby certify that I have prepared this applicatiowand that the work will,,be`done in accordance with San Joaquin County ordinances, State laws, nd rut ind regulations of the San Joaquin Local Health :District. (Signed} ----------------- ----- -.--------`-------� ------ -------------- (Owner a I By:------------- =--- = ............. = ---=-----•`---_------------`------------------------------------------------------(Title)-------------------------------------- - -- - -------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). j F nA FOR DEPARTMENT USE NLY APPLICATION ACCEPTED BY-- 1 -----. -�C—----`� ------------------- --- DATE------9-7-:f -Z--�}------------------- REVIEWEDBY------------------------------------- -------------------------------------------------- --------------------------- DATE_-----------------`--------------------------------------- BUILDING PERMIT ISSUED----------------------------------------- t ---------------------------- DATE------------------------- ---------------------------------- Alterations and/or recommendations:___;-_"""'°_.:___--------- �'__- -•-----------------------------•----- ------------------------------------------------ .. .... b l6��U d �� - - :; : -------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------- ------------ 1 FINAL INSPECTION BY: - - - i� �' -.� Date 1.�J - ---------- -�I-I- --------------- SAN JOAQUIN LOCAL HtALTH\" STRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street r Stockton,California 41i0dl,California Manteca,California Tracy,California \\\ E9-9 REVI9EO 8.89 F.P.77.2M 6.67 L -