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y- FOR OFFICE U$E: __ ___ . ----------- __ ------- APPLICATION FOR SANITATION PERMIT Permit No. --- ------------------- (Complete in Duplicate) / i,, This Permit Expires 1 Year From Date Issued Date Issued .__.'__._..1 - 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 LOCATIO .._170 a~' � � ;� �s p� 'Nom.�,(-�----------------------------------------- ----------------------------------------------------------------------------------------------••-----------... Owner's Name....1 -rd !N_`z'r!x-.......---- -------------------------------------------------------- Phone.................................... ------------ Address------------------ R� .................................................Contractor s Name •-•-` --•-��------•----------------•------•-•----------------•----------------••------•-- Phone..1' Installation will serve: Residence []''•Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other 0 _ Number of living units: __'/____ Number of bedrooms _ Number of baths ._-/___ Lot size ______ ____________ ____✓.5�_= .. 7-5 Water Supply: Public system [](Community system ❑ Private ❑ Depth To Water Table 0 ft. y Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe� an ❑ O Previous Application Made: (If yes,date____________________) No New Construction: Yes �No ElFHA/VA: Yes ;7No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet _____Distance from foundation-/D Septic k: Distance from nearest well_.._..._ .....___.___.Matenal.._..(------_ ______________________________ p j_-1 Size-----. �W Liquid depth--- -------- Capacity... .. No. of com compartments _ .______._____. _ dd c Dispos Field: Distance from nearest well____"_'M.....Distance from foundation.ltl'_..........Distance to nearest lot Dline-. __._`_.... t Number of lines_____---/L________________________Length of each line___ k'_------_-__--------Width of trench---.`•Z-_-._5F-___.___------__-.-.--_ Type of filter material...'-/T�_,;�,_&-.__-_Depth of filter material....lA'-`----------Total length_._.'e2.............................. Seea Pit: Distance to nearest well------- ---------Distance m foundation__,T.�........_..Distance to nearest lot line_Jf__�__r_..._._ P Number of pits---l------.----------Lining material._.__ _.._-':A____-Size: Diameter_Z- -%.c______--Depth........5.7./_____________ 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--------------------------------------------- --------------------------------.-----_---•--•---- -----•----------------------------------- Remodelin d/or repairing (describe):________ __1+�L_ _ _ L' 4____ `��N-4r.,,_____________ --------------------------- ----------- ----- -------_------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------....-------------------------------------.......----.........----- --------- ----------------- -----------------------------------------------------------------------------------------------------....-....-....--------------------------------------------------------------------------- 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 f t San J aquin Local Health District. (Signed)---------------------------------------------- ----------------- ---- - -------- ------- -------------------------------------------------------------(Owner and/or Contractor) By:---------------------------------------------- --- --- ------MM -------- --------------- ----(Title)---------------------------------------- --- - -- ---- ------- (Plot plan, showing size of lot, locatio system in relation 0 , wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY > APPLICATION ACCEPTED BY--..- 14DATE.`. U`" / 1 --------------------------- REVIEWEDBY------------------------------ ------- --------------------- -- _------------ DATE------------ ----------------------- -------------- ----- BUILDINGPERMIT ISSUED----------------------------------------------------- ------------------------------ DATE...-- ---- ------ --- AFFerations and/or recommendations: D ( y ....--- �' - ------------------------------------------------------------------------------------- .......-....................................................................-................................. ----------------------------------------------------- ---------------------------------------------------------------------- -------- -------------------------•--------------------------------------------- ------------------------------• --- ---.-----`.--------------------- -- ----------------------------------------------------------------•-- -------..... ..... ....... --- .........-------------- --------------------------- -------- - ------------------- ----- ----r, -- �`J ------f- ------------------------- ---- --------------------------------------------------------ZE./-----------------------------------............. FINAL INSPECTION BY:. Date----6- (------------- --/ ---v----- ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Stmt 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 2M 5-62 ATLAS