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FOR OFF EUS y p .._-- - ---- APPLICATION kR SANITATION PERMIT Permit No. . J...11._ .Q t ---------------------------4/1A (Complete in Duplicate)___________________________ -- - ----- --- This Permit Ex ires 1 YearTrom Date Issued Date Issued ----- ----------- --- A -_ 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. S49. JOB ADDRESS AND LOCATION_ £;' �'..... :4 ._�.. !�. 'fir ................................................. Owner's Name..--•-••----_� r -----•--` r Gc U 1�-C�-----•------------- •- Phone - ' -------------- � - - ---------------------------- ---•-- Address - Contractor's Name-- I � - --------�--------- � 1 .......... •-----•--------------- Phone-I .6.rK. d Q .... Installation will serve: Residence V Apartment House ❑ Commercial ❑ k Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/___ Number of bedrooms Numb^er,of.,;baths Lot size ___________________ Water Supply: Public system LComra unity system 1] Private 'Depth To Water Table .00. f+, Character of soil to a de fh of 3feet: S�andGravel❑ ❑ Sandy Loam ClayClayAdobe Hardpan E]a , Qi Previous Application Made: (if yes,datef�---•---------------) No [W New Construction,- Yes No E3-- FHA/VA: Yes ❑ Notj' TYPE OF INSTALLATION AND.SPECIFICATIONS: ; (No septic tank or cesspool permitted if public sewer is available witrin-200,feet.) -�. Septic Tank: Distance frorri':nearest,,well_ Z _Distance from foundati6n_ . _,N-4f No. of compartments-------�- ---__--_.Size--:- ---':`_ -- ---•--.L,quid depth....... . ......... Capacity.....&'.. Disposal Field: Distance from nearest well-N.C417-Distance from foundatio" /01 Distance to nearest lot line___,,47!..... Number of lines,___________ `� � �, �-------------------Length of each line__.1 __ ____.�--�-;W''__.Widfih of trench-----------�=�1___._______-- Type of filter material....XR_0g1-.....Depth of filter material_______/_e___ __.To+al length__________________/ P!___.__ Seepage Pit: Distance to nearest well__/ Q j_---Distance from foundation.... -------Disa ce,o nearest lot line....s...'___.- [e CAA Number`of pits----- -----------Lining material--- Si�e: Diameter----------------------Depth-.--_-------2-S---- Cesspool: Distance from nearest well_____--_____---_Distance from foundation-------------------_Lining ❑ ,� . material l____._.____________._________________ Size: Diameter.-------- ----------------------De th----------- --. _ _- _-------- --- -- ---_ Liquid Capacity. ...............• •--••--•-gals. i Privy: Distance from nearest*well-------------------------------------------------Distancebuilding " from nearest building_:__:.____________________________.,___._- t ❑ Distance to'.nearest lot line -------------------•----------------- r , Remodelin and/or repairing describe :_ __-__ - mac.'- -Q-f - a.r___. I ____________________ ---�h '--------------------------•--------•-•--- ¢ ------------- -- ._ .ti/,� r / s =----------- >------------------------- ----------------- - f----- ----•- .. ------------------------------------------------------------•----------------------------------------------------------------------------------------------------------------------------------------------------------------- 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, i (Signed)---- '------------------• -----------. ---(Owner and/or Contractor). � r , By:----------- (rifle) -* (Plot plan, showing size of lot. Iocca�fl f system in relation to wells,',buildings, etc., can be placed on reverse side). t # FOR DEPARTMENT USE ONLY ! APPLICATION ACCEPTED BY -- ------------- DATE----------- ----------------- REVIEWED BY j -----. ------••----.I....................... DATE------ •-----••----2•------•--- --•----_-- •-------------- BUILDING PERMIT ISSUED----- ------------- '-------------------- ------ -------- ------------------------------------- DATE------------------•-=--------------------------------------- Alter tions and/or recommendations: ------ -------- -------•-•----••-----__------••------------------- =----------- �- �. -------- --- ----- ..___ ,�. ..... '._: r ------------------•- ------•-• -•-------------------------------------------------------------------------------------- ----------------------------------------------------- -•-----•----•- --------------- ---------------------- --- - - ----------------- - ---------------------------------------------------------------------- - - - FINAL INSPECTION BY:--- ' + � 4 > 4 -. tDate-----------•---_- =l ------------------------ 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 E5 9 REVISED 8.59 ZM 5.62 ATLAS