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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. gz ....•._-_----------------------------------------------------------- // --------------------------------------- ----- (Complete in Duplicate) Date Issued .-�f•- -� :l � ------------------------------------------ ............. This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District fors permit to construct and install the work herein described. This application made in compliance with County Ordinance No. 549. r -"^r J2q— %QU -Z9 g56,1) V►W' �rfW& `a4 tom `�¢- Ic JOS ADDRESS AND FOCATIC�___S� ` � P:P14.�_l _1_C,TL1F.1 _ _. .t_ ._. . --- --- -- - ----- _ 3 - _ rPhone- Owner's Name W..C,.---- ------- Acldress_j_LC.Td ------------------------------- Name!__ h..`____- - } J 1 �r ` .A.�.a _ y� 1 Q_C--a----------- Phone--- Contractor's Installation will serve: Residence ❑ Aparfriment,House�❑'IC6rnme�,al'❑' i Tfaiier Court ❑ Motel ❑ Othe, X rr i1e� i z' - - - o------- �------------------- Number;of living u.'nits: .__.�_ - Number'°of bedrooms _._____ Numl7er of�baths __�____ Lot size ___..__.mss . 1 it '' �!y .,?�. '"� Water Supply: Public�s�tern ❑w•Community'systerrl"tj Private Depth to Water Table -------- ft. Character of soil to a depth of 3.,?feff et: 11Sared of#Gravel� 5an��Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑� Hardpan ❑ Previous Application Iv'ftde: (If $es date. --.) No ,,._New Construction: Yes ❑ No ❑ FHA/VA: l es [] No ❑ TYPE OF INSTALLM)ON AND SPECIFIC IONS. (No septic tnk or csspoo[permi#tad 1f�publlc;ser 1s $il��ilw+hitt 200 feet.) .� f+ 1!t ^ Septic Tank: Distance from nearest well—_Distance from fnouation_..__ D_...__--.Material--_.lprvc__ -�--9_ !;;�-t-._. 0 No. ofi�corn partments----- __ . __...._.__Size_�lttl@_Gti _�__r.___Liquid depth--------------------------Capacit dtw Disposal Field: Distance from nearest well-.... Distance from foundation------I.0-1.......Distance to nearest lo+aine---1-0....... Number of lines-------------%—---------.-------Length of each line__-______--_ _' Width of trench-------2•,x�0 s Type of filter material____- Depth of filter material-------11!5 4 ----Total length-------- ---------____---__-_ Seepage Pit: .: Distance to nearest well---------------------- from foundatior�.-------------Distance to nearest lot line-____-.._____.._ - t ❑ Number of its__________ __ _ Lining»mat Fiai"*� .,.__,_-_-!.Size: Diameter-._._----.-.---._...__- Depth-._... _---_-_ � i ------------- Cesspool: Distance from nearest well_________________Distance from fln a?ion---_-----._--_-....Lining material,_-----__._It% - ❑! Size: Diameter- ------------------- ---------------Depth-------- - Liquid Capacity----------------------------gals. II ��y' --Distance from nearest well------------------------------------------------ Distance from nearest building-.___------- ---------------- - - ---------------------------- histance to nearest lot line.. ... ......... n'. i Re odelin and/or re-pairin describe . ---------------- -- -- -- ----------------------------------------- -~tea, - -.. ----------,.�...--------------- f / I hereby>�ertify +hat 1 have prepared this application end that the work will be done in.,.accordance with San Joaquin County ordinances,4State laws,'and rules afid regulations f the S°an Joaltri6,Lanai Hvaith District. (Signed).----- - ---- --- ---------- �f -------------- " "" (Owner and/or Contractor) Y ------ --- - - ------• ----- --- - --- ---- --- ------ ----------------------- -------------------------(Title)--------j ------ --------- (Plo�plan, showin size of I , location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- - --------------------------------- -- --------------------------------------- DATE---------- 7 �6------------ REVIEWED -----------REVIEWED BY------------------------ - --- - - ----- -------------------------------------------------------------------------- DATE-------- - BUILDINGPERMIT ISSUED------ --- ------------------------------------------•------------------------------------------.- DATE--- ---------------------------------------------------- Alterationsand/or recommendations----------- ------------ ----------------__-------------------------------------- --•------------- -----------------------------•------------------------------- ---I------------------------------------------------------------- ----------------------------------------- ----------------- -----------------------------------------------------------------•.------------- ------------------------------- F€NAL INSPECTION $ /_ = Date -----------1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California