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FOR OFFICE USE: ---------------------------------------------- _______---_____________ _ _ - APPLICATION FOR SANITATION PERMIT Permit No. ._ZfZ-f/. _ -------- --- - (Complete in Duplicate) -_- ------------- 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 Ord&nce No. 54999. p Cox.;4,.Wjbo JOB ADDRESS AN LOCATION__ @. _ _- -- --- ---s ,oru. 77 1`1 Owner's Name--- - K�.�.�.Y�.. ^ ----------- - Phon -----••------------- `� N t Address � { t + �a � � j DD � t - Contractor's Name-.---C. f`+. - �g�-•--••-- �tr--�---------•------ Phone------------- •------_---•------- - -- --- -- ------ ------ ------ Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: j-_- Number of bedroom� Iber_11'." of baths -------- Lot size sae _ :Q--�_?�.,� ___________ Water Supply: Public system E] Community system rivate ❑ Depth to er Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam JK Clay Loam ❑ Clay ❑ be Hardpan ❑ Previous Application Made: (If yes,date--------- ----- No ❑ New Construction: Yes ❑ NoFHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) tic Distance from nearest well-----------------Distance from foundation--------------------Material-------------------------------_--.-----__.-----. No. of compartments---- ---------------�--Size-------------------------------Liquid dep'h------------------------Capacity----------�-----►^-�- D' osal Distance from nearest well Distance from foundation---;........Distance to nearest lot line__-.ff _...__. Number of lines------- ---- ._-Length of each line-__/-1C0------___.-.Width of trench--- -*-_-_.__-_----.- Type of filter material-- ---Depth of filter material--------/�0"__Total length--------------�p_Q_.�--_---__.- 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_-----.----__--_-_--_--_-------.--_.-. ❑ Distance to nearest lot line ---------------------------- --------- -------------------_- ----------------------------------------------------------------------- . Remodeling and/or repairing (describe):------------ ----------------------------------------------- -------------------•----------- ---------------------------------------_---------------- ------------•------------••------------------------------------------------ --------------- --------- --------- --------------------------- ------------------------- -•-------- -------•-------------------- ------•---------------- - - ------J _- ----- ---- ------------------------------------------------------------------------------------------------------- ---------•----------------------- ----------------- -•------------------ - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State Ja s, and rules and regulations of the San Joaquin Loc4 Health District. (Signed) '" M > .�.�1_.�`� ..... w^ss.x LacContractor) BY: -E6--------------------------------- 1` (Tale) - ------------- (Plot plan, showing size of lot, location of system in relation to well , buildings, etc. can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY,--------------------- --- ----- -------- -- --------------- _ --- -------- - -- DATE..........��- -- ------------------------------------- - REVIEWEDBY--------------------------------- -------------------------------------------------------- ---------------------------------- DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED--------------------------------- ---------------------------•-------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations--------------------------- ----------- ---------•------------------------•------------------•-----•--------------------------------------------------------- -------------------------------•--------------------•---------------------- ------------------------------------------------ -------------------------------------•------------------------------------------------------- -------------•-----•---------------- ------------------------------------------- ----------------------------------------- -------------------------------------------------•- ------------------------------------- -------------------------- •----•---------- ----------------------- ---------------I---------------------- ------------------- ---------------------------------------------------------------•------------------------------------------------- ------- ---------------------------------- ------------ ------------------------------ ---------- -- ------------------------ l FINAL INSPECTION BY:.--- . � - -- ----- ------------ ------- Date- ---~ -f----- - --- --- ---------- .. .------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California _/tL,odddi,California Manteca,California Tracy,California F.P.0 —v7O. alt