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FOR OFFICE USE: �442g�� _-:-_3,_:3Q-_-_-. APPLICATION FOR SANITATION PERMIT Permit No. ------------- --- - - - - �1 (Complete in Duplicate) / ,/- `�, l Date Issued ._:� ,l ------------------_._. ___,_ _----_-_-___.___ This Permit Expires 1 Year Erom 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 Ordin No. 549. r� �� a. - JOB ADDRESS AND LOC ION --r-� ---------------------------------- Owner's Name----------------�`.__.__ �----•----•--•_... -- _— Phonel f.- r�� Address -----•------------------- ------••-----------------------------------••----------------•------------•---...----------•---•-------.......... /t p Contractor's Name------ ...... ¢ �1J►%�'...... l' ................................ PhoneA_.6_3.._V Installation will serve: Residence.Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other rr❑ Number of living units: _ _. Number of bedrooms .7Number of baths ___/.. Lot size ....1.144-(x_ r.. 4�. `le --- Water Supply: Public system e Community system ❑ Private ❑ Depth to Water Table _eeft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe(CHardpan ❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ No „,FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: -"(Wd septic'tatrk-oucesspool permitted if public sewer is available within 200 feet.) .c Ta ance fromrarest well_________________Distance from foundation....._--------------Material.•----------------------------------------------- No. of comparOnents--------------------------Size--------------------------------Liquid depth--------------------------Capacity. .......... ' f?istance from nearest welLAVNA-- Distance from foundation... .. .........Distance to nearest lot line Number of lines__,*_�___ __________________Length of each line______9...Q__.!!f.��...Width of trench-_--C. �. .:....___.... Type of filter material.1 Zi -s-_-Depth of filter material...-(�.-______Total length..._ O__ _____________________ See a Pit: Distance to nearest well_1►1`4M�__ -----Distance from foundation---4-7....._..Distance to nearest lot line..va?_. _ Number of pits___________________Lining material._&Q.r� .... Size: Diameter---�' .3.�r___.Depth_..__r�_:S.__.�......... 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-----------•- -------------•--------------------------------------------------------------------•------------------•-----•-------------------- Remodelingand/or repairing (describe):...............----------------------------------•------•--•--•-----••---•----•-•-••-••-------•----•-----------------•--••---------......-•---------••-- -------------------------------------------------------------------------------------------------------------------------------------------------- - ------ •----------------------------------------•------------------------------------------------------------•------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, a laws, and rules and regulations of the San Joaquin Local Health District. (Signed) -• ---�=--- 4 , a---C i ......CT_ - -----------• .Contractor) By:------------------------------------------------------------------------------- (rtle)--------------------------------- (Plot plan, showing size of lot, location of system in relati o wells, buildin etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------ --- �------ ---•-•------•-------•------•-----••--•----. DATE REVIEWEDBY------------------------------------ ---------------.•.--------•-----•---------. DATE--------- ---•-j----••. -•----•--•---•-•------------- BUILDINGPERMIT ISSUED............-------------------------------------------------------------------------•--•----------• DATE.......................................................... Alterationsand/or recondations:-.---------------------------------...--•----•------•-----------------•----------•--•-----------•----•--•-----------------------------. ! '----------91%1--r------------------------------------------------------------•-----------------------------------. --------.._... ----------------=--......--------------....•----------•-------------------------------------------------------------------- ------------------------•------•------------------------------------------------------------•--- - ---- ---------------- -----•---- 7I . INSPECTION BY---- --------- ---------4-=-- Date----- - --------- ---- .... ------ C---�------ SAN JOAQUI CAL 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 Ce-9 Rrvlero a-39 r.P.Co.ZM 6-60