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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. J.-a13... �... (Complete in Duplicate) y/j -------------------- --- ------------ ----------- --- This Permit Expires 1 Year From Date Issued 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 AND LOCATION-_-� --- '--11/ 'I • � � � �� `' � Owner's Name------ ----- 4 ------------------ --- P gne----------------------------------- Address----- ��f 1' �c = _ _ C'f3fd �-•--- f,�', ---_------------------- Contractor's - ----- - ------ Contractor's Name___, .-- -_ 1 I� ` ter/ . -=------------------------ Phone `� � Installation will serve: L Residence,❑_Apartment House❑ Commercial �ir Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1--- Number of bedrooms -------- Number of baths ...._-_. Lot size -_-. �.1 ---------- Water Supply:- Public system ❑ Community system ❑ PrivateDepth to Water Tablet. Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy oam�Clay Loam ElClay [3Adobe❑ Hardpan ❑ Previous Application Made: (if yes,date-----------:--------) NoNew Construction: Yes No ❑ FHA/VA: Yes ❑ No ❑ r TYPE OF INSTALLATION AND SPECIFICATIONS: � � ��` p,,�,,,t�� , 1 „(No septic tank,or cesspool permitted if public sewer is ava e t to 20 feet.} Sep is Tank: Distance from nearest well_- 1--..-_Distance from foundation---/ --------Material------- No, of compartments,.--?--"--------------- Liquid de th-_, �-��--------- Capacity.., _ r ! Dis o I Field, Distance from nearest well-,1- 72---- Distance from foundation_-X1.2-----------Distance.to nearest lot Gne. ..-_..... Number of lines-----.Z-------------------------Length of each line-/D_Cl_-�.-a -�-Width of trench.--,� r�--------------- S Type of filter material--- QCf,C-----Depth of filter material---- --_----Total length-----1. -49----------------- Seepa' Pit: Distance to nearest well �Q-.------Distance from foundation----/0-_--.._-_.D t cue to nearest lot line--, ---~---._ Number of pits------ e-----------Lining material..-,P�4(-/�_-.Size: Diameter---I---------Depth------,,_��• ------ ��?- ess ool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material--.--..-----__--_----_--._--_-_-----_. ❑ Size: Diameter--------------------------------------Depth---- -----------------------------------------------Liquid Capacity-----------------------•:..gals. Privy:I 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 ordinance tate laws, and ru`lesand regulations of the San Joaquin Local Health District, x I - ' - Owner and/orContractor) :: .-(Signed) r�$y.. (Title - - , ...----•---- r - ------ ------- � (Plot plan, showing size of.lot, location of systerri`in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------------- ------------------� --- DATE--------------- REVIEWED BY-------------------------------------- ----- DATE. BUILDINGPERMIT ISSUED---------------------------------------------- _,,--------------------------- DATE-----------_------------------------------------------------- Alterations ------------------------------------ • - Alterations and/or recommendations:----'--- -:.:-,_s --- . . � - i f -----------------•------------------ ------------------------------------------------------- ----------------- ------------------•---------------------•------------------------------- --------------•--•-------•------ -:.--....--------=----......---------.-..-....-------------------------------------------------------------------- ----------------------------------------------- ----------•---------------------------- ------ -------------- -- -------- r FINAL INSPECTION BY Date_, 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 EB•9 REViFJEO 6.59 Fr P•C C.1M 6.6C S