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FOR OFFICE USE: 771 ---------------------------------------------- ---------- __-___..._. ---------------t__ .._.._..___--_._... APPLICATION FOR SANITATION PERMIT Permit No. .__/. (Complete in Duplicate) ;C - 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 described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND—LOCATION.........;._O_Iyq------- AIJ Owner's Name---------- . 1-----------1--P arl_ :0------------- --------------------------------------------- Phone.................................... Address................................Z�.5*.� - Contractor's Name----------------....J .041F.•----•-------•-------•-•----------------•---------•---.....--------------••-----------•---••---... Phone................................... Installation will serve: Residence ®, Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 1 � Number of livingunits: .....__ Number of bedrooms _- -_.. Number of baths --�---. Lot size ---- .._'Z.1$b--•---•---••.................. Water Supply: Public system dK Community system ❑ Private ❑ Depth to Water Table _a.6. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 4 Hardpan ❑ Previous Application Made: (if yes,date....................) NoWj, New Construction: Yes ❑ No ® FHA/VA: Yes ❑ No [ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if M.4-c5-- ewer is available within 200 feet.} Septic Tank: Distance from nearest well... Distan e froom; fyundation_---- P..........M t rial_. - --.-•-_-•-•. No. of compartments_.__..... ...... ....Size---- 1(,1•7.?�9_-_--_-_._•-Liquid d7pth__._.��---......._-- Capacity..... . Disposal Field: Distance from nearest well__ _ kC...Distance from foundatiorjj AQ_...._....Distance to nearest lot line-_ .......... Number of lines _ _.�_.__.. Length of each line__.._.-_a -r.............Width of trench.._.,a.,....... V----- ----------- 1 Type of filter matenaL2--------------------Depth of filter material-.1.0----------------Total length......FC1___..............-.._....._... O Seepage Pit: Distance to nearest well----------------------Distance fro mi ,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 nd/or repairing (describe):-----------"k!. "I C�GS�,"... _..__ •• •_.• _ '-••-•-•---------•-.--------•-------------•-------_----- ................................ ~ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ I 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 rules and regulations of the San Joaquin Local Health District. (Signed)- = (9Z _4 � ------------------------------- (Ovin)and/or Contractor) By:_- ---------------------------------------------------------------------------------------------------•--••--••--•--•--•---•••(riifle)--------------------- (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 APPLICATIONACCEPTED BY----------------- ---------- -------------------------------------------•--------------- DATE. fD t REVIEWEDBY `------- ---------------------=---------- -- - -----------------•-------------------- DATE------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE................ ..................................... Alterations and/or recommendations:.-------- ---- ------- -- ----- - ------ ---- -------------------------•------------ � .----- ,----- ....... ----.--._.• .. 1�3� - ------ -- - - ------- ---- ��' r trod • -----•---------------•--••---------• --•--•------•- -------1�• ------- -- FINALINSPECTION 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 EB-9 REV1890 B-59 F.P.CC.ZM 6.60