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FOR OFFICE USE: - __-----____________ --------------------- APPLICATION FOR SANITATION PERMIT Permit No. -�_.3 .�`T....2-- ---------- ---- -------------- (Complete in Duplicate) Date Issued ___ _____ ----------------------------------- I This Permit Ex ires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION / _I 1'V- l�1-. �N -...----•-------. -.._._.. Owner's Name-_�[N-T-JN=----Q4—vpk 4----- -------------------------------- Phone..J....... -•---------------•----I Address----•-----------•-� � 0S: ...------•--•-•--------•-••----•---•--•-••-----••--------••------•---•--------•--•--------•------•--•--•----------------------•--••----•--------•-----•------•--------- Contractor's Name-------------p�--J- --------------------------•-=-----•-•---•-• Phone----------------------------------- - Installation will serve: Residence Apartment House ❑ Commercial E] Trailer Court ❑ Motel C] Other [INumber of living units: j.... Number of bedrooms .3-- Number of baths .2.. Lot size __l J� _.__�J� ................. Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ........ ft. . Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam E] Clay Loam E] Clay ❑ Adobe ardpan ❑ Previous Application Made: (If yes,date---.----------------) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septi T k: Distance from nearest well-10-C7------Distan a�/from foundation.....rQ_........Mat rl.... ---------------------------------- No. N00�---.---.-_-•. No. of compartments — ---_-----_-Size_PX1.O X� Li uid de th__.__ _--_Ca acit --2© '� P µreit q P. P Y� - ------- Disposal Field: Distance from nearest 7111!"-10-0---._Distance ff� ation.....I __--_.-.Distance to nearest lot l/ine�J..---.-.--- ,,/ Number of lines._..._.____ ---------------..Length Qf eadh , 'n€_ Width of trench.___._-. L.2..-_--.-.__.._...._ \ L'l Type of filter material--�_.EPTiL__KocKDepth of filter material_____�_z1.,_-_____._Total length___ ` .._ Seepage : Distance to nearest well- /O42-_._-_.-Distance from foundation..__1Q__........Distance to nearest lot line [ Number of pits---------1------------Lining material--_RV-��-_.Size: Piameler_� x -/Q......Depth_----:.!9--------- - --- Cesspool: Distance from nearest well-----------------Distance from foundation-_-----------------Lining material............ ._-.__--.-__--__---_._.__.. ❑ Size: Diameter-------------------------------------Depth---------------------------------- ----------------.Liquid Capacity............................gals. from nearest well-------------------------------------------------Distance from nearest building_-_-_-----._.-__--_---_.-_.. Privy: Distance -------------- ❑ Distance to nearest lot line o- line-------- ----------, --�- - --- ------ -•----- �----- ----•-----�---`------------ •- -• ---• �--- -(------- s Remodeling and/or re irin d tribe):_-- t - ' / 14, ---------------------------------------------------------------------------------------------- - --------------------------------=-------------------------------- ---- ------------------------------------ ------•--••------------•-------••••------•------------•••--•-------•-••--•-------•---------•-••-•••---••----•••----------•---•------------•-----------••-----••••-------... ------------- 1 her certify that I have prepared this application and tha the work will be done in accordance with San Joaquin County ordinan es, ate laws, and rul an regulations of the San J quin Local Health District. (Signed)_ - --- - ------------------------------ ------(Owner and/or Contractor) ------ --------------------------------------------------- y: (Title) --- ---- --- - - --- - -- - (Plot 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-----—7 R_.©' ------- ---------------------------------------------------------- DATE-------4..—/'7!777&-f- ---------------------- REVIEWEDBY---------------------------------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE--------------------------------------------------------------------r �--)-------------*----*---------------------------------- - Alterations and/or recommendations•--------- ........................................... --------------------------------- --------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:.---------- - --------- ---••- Date -- ------------------ / ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California Ee-9 REVIMED 8.69 F.P.CD.2M 6.60