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1-UKUFFICE USE: ------------------- -----------------------------. ________________________________________..__-----_____.- APPLICATION FOR SANITATION PERMIT Permit No. .l...�.12__ ..� -------------------------------------------- ---------- (Complete in Duplicate) Date 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 esced. This application is made in compliant with County Ordinance No. 549. JOB ADDRESS A OCATIO � ------- ---------14 -- = -_ Owner's NaPh - ------------- -- ------------------ ------------ one Address = .n�'JY `5 ' Contractor's Name- ------- ----- l ------------- , - Phone...... Cb_t3 " &SCS =-D? -- ---- ------------------- - Installation will serve: Residence WApartment House ❑ Commercial ❑ Trailer Court ❑ Mofel ❑ Other ❑ Number of living units: ----F-- Number of bedrooms,,r�__ Number aths --- -_ size ________ Water Supply: Public.system ❑ Community system El Private Depth t afer Table ........ ft. Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan-❑ Previous Application Made: (If yes,date-------_.--_------- No ❑ New Construction: Yes 0 No ❑ PHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank-of=cesspool ermit4a'�'if'pubic is ai b!within-2 0 feet.) Septic _-�-- r' - -- Tank: Distance from nearest well_________________Distance from foundatison__--.--_-_________-Material___.___________.__._-____._.___..____.----______. ❑ No. of compartments--------------------------Size--------------------------------Liquid dept ------------•=-----------Capacity----------------------- Dispos ield: Distance from nearest well----4� 0----Distance from foundation-------lU_.....Distance to nearest lot line----45--/_- 00 Number of lines___._:__--- ""'Length of each line----,Gl---__�_-._----____ Width of trench______�----------.-------•-- "4 Type of filfer material_ - ._ -_ - y �Depfh of filter material_-_- ____.-Total length 9 cru------------ �_. Seepage Pit: Distance to nearest well----------`•-_+____,-Distance from foundation--------------------Distance to nearest lot line____ !E [] Number of pits------------- --- ----Lining material-----------------------Size: Diameter---------------- -----Depth--------------------------- f > Cesspool: Distance from nearest well-____:__-„ -Distance from foundation____________________Lining mafierial__..____--___-_.______._______._.__ C r-..,.�•.� 0 ❑ Size: Diameter ----------Depth-------------------_-------- -----------'-----Liquid Capacity------------------------- gals. .+ Privy: Distance from nearest well------ ------------------------- -----Distance,from,nearest building---------------------------•--------------'T ,- ❑ Distance to nearest lot hnea.__ ___r Remodeling and/or repairing (describe)_._ ----- ----- •---- --- ,Yk -` __- _ _ � T_ ______'�'_.-�_--_ _ - __E_ __________-••----------------- __ _ __-________.___.-------------------------------------------------------------------------------- r� I hereby cerci of I have prepared-this application`and that the work will 6e done in accordance with San Joaquin County ordinances, Sta aws, )and rules and regulatio of the San,Joaquin Local Health District. (Signed)-,-- - f - / rContractor) -------------- - -Ir+I+;)- -='-�---------------- -- --------- ----- - (Plot plan, showing size of lot, 'location o system in refafi n to wells,"buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -sem -------------- --------------------------------- ------ DATE--- --lJ"" —------------ ----------------- REVIEWEDBY-------------------------- •---- --------------------------- ----- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED-------------------------------------------------------------- ----------• DATE Alterations and/or recommendations---------------------- --------------------------•----------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------•----- -----------------------------1-1-----------------:----------- -------------------------------------------------------------------------------- FINAL INSPECTION BY:- p ----------- Date..... -"/ ------------------------------------------------------------- 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 ES 9 RMSEO 6-59 3M 3•'63 P.F.CO.