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FOR OFFICE USE: --------------------------------------------------------- - - APPLICATION FOR SANITATION PERMIT Permit No. __1. &Z...... --------------------------------------------------------- (Complete in Duplicate) This Permit Expires 1 Year From Date Issued Date issued /Q Q Application is hereby made to the San Joaquin Local Health District for a permit to co s ork herein des ri ecl. This application is made in compliance with Co my Ordinance No. 549. 1. Sy JOB ADDRESS AND L, CA ION---.. --- - -_..L_--j_--....... --•G%Q� �P.1L�L�. .___-•• -•-C�.44°1� --------- - Owner's Name--------Z �'1 ---•-----.. ---`---------- --------------- Phone.........----- ------------------ Address.-.....----------•----------------- 5 �---•----------------------------------------------------------------------------------------•---•-•------..-----------------------•--------- Contractor's Name.......... •-------------< -_AA41 - -•-------------------------------------------------------------------------- ------- Phone----••-•--—------------------ Installation Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court E] Motel ❑ Other [] Number of living units: ___rNumber of bedrooms __Z-_ Number of baths -------- Lot size ---------- 11 Water Supply: Public system ❑ Community system ❑ Private KDepth to Water Table -------- ft. 1 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 ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (Nos fic tank or cesspool permitted if public s�wer is available within 200 feet.) `eptic Tank:^ Distance from nearest well____ _____Distance from foundation--------------------Material----------------_--_--_-_-_-_�_---_-__----_--_----. ----- C --.----------------------� ------ --- � Ycs-- !L Disp sal Field: Distance from nearest well_._.�!_O_.__Distance from foundation----/_ ______---Distance to nearest lot line-------- 1. [ Number of lines________________ _---____-___Length of each line-_-____________�O-__.___-Width of trench.__________�_______________.__ Type of filter material_�-__G_ __ ---------Depth of filter material-------- ___------Total length------------ITC`:._............ .__.. Seepage Pit: Distance to nearest well---------.------------Distance 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-------------------------------------------___._Distance from nearest building------------------------------------------- 0 Distance to nearest lot line-- --------------------------------------------------•----------------------------•-------------•---------•----------------------------------- Remodeling and/or re!� i..ing describe):---------- -- ---------- : ------....- -•-- --------•--------•----- •------ ---------------------------------- -----------•-----------•-- ... � `' l Ply- �1I-----Ae.14__.--••---------•.1C�_ .. ------------------------------------------••------------- -----•------------------------------------------------------------------•- --------------- ••-------------------------------- ------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat laws, and rules and regulations of the San Joaquin Local Health District. ' Signed) __________________? ^�+. I � 2 i ''� _ ---_.__Owner and/or Contractor ( / f By:-----r------------------------------------------------------------------------------------------------------------------------------(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 APPLICATION ACCEPTED BY ---------- DATE 3 _ r..._._ REVIEWEDBY------------------------------------ ----- ---------- ---------------------------------------------- DATE.. ..-'"__..___....--------.....----.......... ..._ BUILDING PERMIT ISSUED--------------- - DAT • -------------------- -------------------•------ Alterations and/or r ommendations.._--" ---"----_- -- ------ _• ----- ----._- _ _. _____________________________________________________________________________________________________________________ ___________________________________________________3F_.._. _____.__._-___ _ _-_-____..---_ _ �,.____-_._____� � ---------- •--------- - ---- !_. 3�:rAV -�✓"s` .._._ ... ........... mi'" ------ 1s �rW'� i r ------- '�f i►^!'�Mar rs O1 e FINAL INSPECTION BY:--- ---------------ry ^- Date �f - ...f�es ( {� SAN JOAQUIN LOCAL HEALTH DISTRICT t' 13111South American Street 300 Wept Oak Street 124 Sycamore Street dl est 9�h-S#r e Stockton,Califotnia Lodi,California Manteca,California y,California Ce•9 REVIREO 6-69 F,P,CO.gM 6.60