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FOR OFFICE USE: " -"-------------_----. - . APPLICATION FOR SANITATION PERMIT Permit No. ___1..��.0.... - - ---------------------------------------------- -- (Complete in Duplicate) J-11 ��(� • Date Issued -------- ---------v5 _____________________________ ______________________"._._ 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 ftheark herein des ibed. This application is made in compliance with County Ordinance No. 549. cc� JOB ADDRESS AND ATION_�__f7,4 /k ---4w_*-- �'1Gr 1 O� Owner's Name___ _x,-7---- -------------------------------- ----------------------------------------- -----------------------------"_.'----Phone-- -- •--------------------------- Address ------- - -----• Address------- ---------� 6� -• ------------------------------------------- ------------------------------ -------------------------------------Name------- •--------------------------------------------- Phone -- Installation will serve: Residence [j Apartment House[] Commercial ❑ Trailer Court ❑ qqMotel ❑ Other Number of living units: " `_' Number of bedrooms _ - Number of baths o2— Lot size lwGci` _,,l _-{ ------------------ Water Supply: Public system ❑ Community systefin ❑ Private Depth to Water Tablesift. Character of soil to a depth of 3 feet: Sand ❑ G`ravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date-----------.-.-_ "} No New Construction: Yes o ❑ FHA/VA: Yes ❑ No P^— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest welL__,W---Distance�from foundafion__/r-_________-Mate�al". _G.f�i �_ __ _____________ _p E4�' No. of compartments----_'�X------------------ dV' 'W Liquid depth__.-_-------------Capacity�a�l�_-__. I _Size ��yy • Disposal Field: Distance from nearest Distance from foundation. /.�---------Distance to nearest lotline___s�"..... Number of lines____________ Length of each line__ 1f r�� - -- •_ �f_�.r�'rX� Width of trench- �----�------------------ Type of filter material �� Depth of filter material---1�`_:____._Total lengfh--"-..._"a�V______________________ Seepage Pit: Distance to nearest rwell----------------------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---__---_____--------_-_-"_-_.-_-_.__.-._. ❑ Distance to nearest'I15t line = ------••- ------------•---------------------- ------------------- 4Remodeling and/or repairing (destribe�:_____.. ____ __ ____ __ ___ .-�f �- --------- 0+ ----------- = - ------------ --------- J;:4 ----------------- ---- --'-- ------- ------------ 0 ------------------------------- •----------------------•----------------- ----------------------------------------------•-------------- --------------- -- -------------------------------------------- ¢r 1 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 r les and regulations of the San Joaquin Local Health District. _. r Contractor (Signed)--- -- -------- - ---------- ------- -{Aw�p By:.-•------------------------------------------------------------------- {Title) .��/ -...... (Plot plan, showing size of lot, location of system in relati o welts, buildings, etc., can be placed on reverse side}. FOR DEPARTMENT USE ONLY / APPLICATION ACCEPTED BY------------------- V`$---------- ---------------------------------------- DATE--------/1 2 3---------------- REVIEWEDBY---------------------------•----------------- DATE BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------ ------ DATE---- --------------- ------------------------------------ Alterations ------------------------- - Alterationsand/or recommendations:-------------------------------------------------------------------------------------- ----------•------------•-------•--------------------------------------- -------•--------------------•----------------------- ------_-------------- -------------------------------- ----•----------------------------------------------•---•------------•----------------------•------------------ -------------------•------------------------------•----------------------------------------- -•- -•-------------------------•--------------------------------------- --------------------------- ---------------- --------- ------------------------------------- •--------------------------------------------------------------------------------------------- ------------•---•-•----------------------------------------------------------------- -----------------------"--------------------------- •------------- - --------- CC---------------------------•------------------------- - •---------------------------"---//------------------------------------------- FINAL INSPECTION BY------------------ - - --------------- Date------- ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1 a 1401 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street +, 205 West 9Th Street Stockton,California -Lodi,California .Manteca,California, A. Tracy,California i VS 9 REVISED B-59 3M 3-'e3 r.P.CD, } lf[