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FOR�- OFF CE SE: �3 � � .------ 9 1 . ----_7�j7_-------.._`�`�7 APPLICATION FOR SANITATION PERMIT Permit No. .. .... .........�. -------- ----- -- -- ----------------------- - al (Complete in-Daplicate) ----------- --- 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. 11 -----------------------------•--------------------------=----------------------•-• -------------------------------------- JOB ADDRESS A LOCATIO--Ncc_____�__I_d"v_____I.':. Owner's Name__�I�p&a�-In e � ® - ----------------------------------------- Phone--:-------------------------------- `'3S �o .,�a.,t _ -------------------------------------------- - NameLam'`"" ------------------------------------------------------•------------------------------------= Phone. .... -- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __1____ Number of bedrooms ___;L Number of baths _.Z___ Lot size _o'0_'X fS�__..-_ -- Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table 1#_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [fl-'Hardpan ❑ Previous Application Made: (If yes,dote-----------_----_____) No 09"' New Construction: Yes [>"No ❑ FHANA: Yes ❑ No [�}� TYPE OF INSTALLATION AND SPECIFICATIONS: 4 (No septic tank or cesspool permitted if public sewer isavailablewithin 200 feet.) L Septic T nk: Distance from nearest well__ _____Distance from foundation ��_ Maaterial___!------------------------------------------ ---------- ?`_ :_________:._..______ __________No. of compartments- -_-X--_ _____ xLiquid de th__ Disposal Field: Distance from nearest well...._'"-_--_--_--Distance from founclation.l_Q_!_______-_..Distance to nearest lot line..--___--_.... Number of lines----I______ Length of each line___9a-P_________________Width of trench----2 9-"_______.__._._______ Type.of filter material6G'�_______Depth of filter materiallf'_�-_____________Total length______!-8__--___..-.--__..-,.___..___- r Ss Seepage,Pit: Distance to nearest-well__..__`1.____.__-Distante�, ��from foundation-36______._-.Distance to..nearest lot line_________________ Number of pits.__:�'___.________Lining material___II<60k______.Size: Diameter__,33__`----------Depth--.__2a----------------- Cesspool: _2a _______________Cesspool: Distance from nearest well_________________Distance from.foundation_-_.----------------Lining maferial-----.______________________________- ' ❑ 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):------------------------- -------------------:_-------------------------- -------------------------------------------------------------------------•--- 1 ----------------------•-------=-•------------------------------------------------------- -------------------------=---------------------------•----------------- ------------------------------------------------ --------------------------------------------------- ----------------------------------------------------.-------------------------------------------------.------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------- --- - --- - I hereby certify that I have prepared this application and that +he work will be done in accordance with San Joaquin County ordinances, State Paws, and rules and regulatio4ofjheSan J quip Loca! Health Distric+. (Signed) -------------•------------------------------------------------- --{Owner and/or Contractor) By:---------------------------------------------- •------- -- -----------------------------------------------(Title)--------------------------- _ ------------ ---------------- (Pro+ plan, showing size of lot, location of system in relatio to.wellx, buildings, etc., can be placed,on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-----9- tl .........___---------------------------------------------------- DATE.._7-_ z-_4_-. `3------------------------- REVIEWEDBY-------- --------------- ---------------------------------------------------- -------------------------- DATE------- ---------------------------------.__..-----•-------- BUILDINGPERMIT ISSUED--------------------------------------------------------s ----; k-------------------------`DATE---------------------------- ------------------------------- .________.__--_ ------------------------ Alterations and/or recommendations:___Z - -__-____t-----------l � Q - --" ------------------------ ----------------------------- ------ --------------------------------------------------------- --------------------- --------------------- -----------------------------------------------------------------.--...------------------------------=--------- -------------------- -- --------------------------------------------- -------------------------- FINAL INSPECTION BY:---- '-sat ------------------- ---------- Date------- -------------- ---------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ma:ellen Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California T Manteca,California Tracy,California I E5 9 REVISED B-59 3M 3-'63 F.F.CD.