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FOR OFFICE USE: _1v 04/6!3------- - ----- --I X-11 ----------- APPLICATION FOR SANITATION PERMIT Permit No. ._ _._. ... ------------------ - --------------- (Complete in Duplicate) /6�CJ --------------------- - . 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 A�N•-D�LOCATION....... .1._ - ._71f N--- --------- - "---------------'S'-_..._..., IVT OS. ----------•----. --------- Owner's Name------ 1'A ........ --------------------------------------------------------------------------------------- Phone._1+.�k-q-i--(0-ta------ Address-----------�-2--1............. --'-......... .l._ ..K_L .` ------- Contractor's Name...........-D_ ...'-- ,.. � p n-�•i e*'�-•----------5 0.N.-i1------------)_-k.r_.------•-------. Phone.... `��q` ...... Installation will serve: Residence ❑ Apartment House 1% Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 1 Number of living units: -��__ Number of bedrooms -1-0. Number of baths -I*Lot size -j_S.Q.........X....2.Q0.................. Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _L0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date---.-_.--..._..__-.) No x New Construction: Yes ❑ No j' FHA/VA: Yes ❑ Nor 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_________________Distance from foundation--------------------Material------------_--.____-_.-,_-________--.-_-_____--. ❑ No. of compartments-------- -----------------Size----------------------------....Liquid depth--------------------------Capacity---_----------------- Disposal Field: Distance from nearest wellNDAiC.._Distance from foundation..... Q.........Distance to nearest lot line..... Number of lines----------!%-------------------Length of each line----------12-a ---------Width of trench............ - f_'.:.&,_.____.__ Type of filter material _ ___ al___ -___.Depth of filter material length_______________ ____ ..... t i Seepage Pit: Distance to nearest well-blOA//....Distancg from foundation....,40_....-__.Di;tante to nearest lot line------ V Number of its_-.._.- i'D - L p �-:___.....Lining material_._ _G/�._-.Size: Diameter____ �.__._.___Depth_____.___�, _________ Cesspool: Distance from nearest well-----------------Distance from foundation.-------------------Lining material__-----_-.-______-._.................. LA ❑ 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):............ CIV- _� --- --_____EXl5-sT1 �r _.__cS", l��..A0- --_--____-______-___-___-___. ---------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------- --------------------------------------------- a -----------------------------------------------------------------------------•-------------------------------------------•--------------------------------------------------------------•----------------------------------- y ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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. ,Q r (Signed)-------------= � '------41 - - 'OOK--Is,46--a...�------ '----------------------------(Owner and/pr Contractor) r --------------------------(riifle)------- -- - -- ---- -------- (Plot plan, showing size of lot, location o system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------- tr-- --------------------------------------------------------- DATE...--.. -'�- 6 -------------------- REVIEWEDBY------------------------- ------------------------------------------------------------------------------------ ------ DATE............................................................ BUILDINGPERMIT ISSUED-----------------------------------------------------------------------------------.................. DATE------------------------------------------------------------- Alterations and/or recommendations:. - 'or ------------------------------------ ----------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- --- FINAL INSPECTION BY:--- ------ --------------------- Date------`' �� =... ----------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B-59 3M 3-'63 F.P.CO. e