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FOR OFFICE USE: - -- ---------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ...1___ _ _ - (Complete in Duplicate) Date Issued `rr--_ � - This Permit Expires 1 Year from Date Issued Application is hereby made to the San Jcfioaquin Local Health District for a permit to construand install e�rt e work erein described. This application is made in compliant with County Ordinance No. 549. z5�q _N SUCH FW JOB ADDRESS AND LOCATION - -- -- - - -.�- 4rY��!�'-f/----�6.M--- Phone •- Owner's Nam n, - ---- P -------- -- -------- ------------ -- ---- hone c , Address - ,�_ — _ Contractors Name ----- -------- ---------- ---- Phone.._..----------------------------- Installation ---------- --------•--- --Installation will serve: Residence ❑ Apartment ouse ❑ CC mmercial ❑ Trailer Court ❑ Motel ❑ Other s Number of living units: __I--- Number of bedrooms ._% Number baths ---f___ Lot size _...__________________._._._._.__ _------__-__--_--_ Water Supply: Publicisystem ❑ Community system ❑ Private Depth to Water Viable -------- ft. I y Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan Previous Application Made: (If yes,date----------------_1 .No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: [N septic tank or cesspool permitted -if public sewer is available within 200 feet.) 1 Se tic ank: Distance from nearest well-----..d_r�a__Distan from`foundi;ion_.__6_C7_._..---.Mat ri l-____ �- -__-.--. P No. of compartments___._____________Size_ _, ___Liquid depth__-.-�.-�..------- Capacity �S Disposfield: Distance from nearest Distance from foundation__._a�- ____.Distance to nearest lot I;ne---------- Number of lines-------_____I___ _ Length of each line...._ s !? r� Width of trench T ' e.of filter material___j� De th of,filter_material___--/ - Total length__;_-�C�_____________________._._. Seepa it: Distance to nearest well----&)6_.-�--Dsstance f5pm, undation____ _______.Distance to nearest lot line-----,cS__.---..- Number of pits___.____(--_-.-_-__-_Lining materi _0�____�----Size: Diameter___.Z.��--__Depthcxc��----------------- yCesspool: Distance from nearest well-----------------Distance from foundation---------------------- Lining material------------------------------------- P. Size: Diameter------- -----De th--------------------------•-- -------------- -----Li uid Ca aci als. ❑ p 4 P tY--------------------- ---9 Privy-' -----------------.Distance from nearest.building--_-_------------------------{_..--__ .�' Priv Distance from nearest well-----_------------------------- - ---- - --------'----'- ' � ' 3 ❑ , Distance to nearest lot line------------------- --------- - ------------------------------------ -------------------- ---- Remodelingand/or repairing (describe)=-------- --------=--:--.---:----------- ---------------------_----------------------------------------------------------------------------•------------- ---------------------------------------------------------- --'----- +. '. -______i- -------------------------s----_-_---------__-_--.----_______._--___._-_----__-____.---____--_-..__._....--_._--_-----__-__-_-_______-----_______--------_----___---_---------_.--_______-_-_____.___-__-.---___. ---------------------------------------------------- ------------------------------------------ M *j " l.'hereby certify f f I have prepared this application and that the work will be done in accordance with San Joaquin County 1.. ordinances, Sfafe l - s nd rules and regulations of the San Joaquin Local Health District. 4 (Signed)----•---------• ----- --------- -.--- - ---------- --------'- -- -------------------------------------------- ------------------------ d ---- /or Contractor( `, * 1} . -- BY --' ----- "---'----- --- -----------=--------------------------(Title)--------------------------------------- ----- --' -------- -- (Plot plan, size of'lot, location of system.in relation f ells, buildings, etc., can be placed on reverse side).— N FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_'. DATE-- ` � _� - T ' ------------- -$ --- - ------------------------------------------------- ---- --------------- REVIEWEDBY.--- '.------------••-••----- " -� --------------------- - ------------------------------------ DATE--------"---•----------------------------------------------- BUILDING ----------- ------BUILDING PERMIT`ISSUED- =_ _� - --_ N' - = DATE _ Alterations and/or recommendations=------- --------------------------------------------------•--------------------•------------ •••-------•-------------•-••-•-------------------------; -------- -------------- -__---'-----------'----"-' T _-.- --------------------------------------- `------------------------------------- --------------------------------- •-------•---------- -------- - -------------- ...- - 1. 1. ..._---- _w.y,. --f 51. - --------------------------'---- _ ------- t. v � � FINAL INSPECTION BY:_ rye. _ _ -- -- Date_.`."_�. /-.ter 7 - kk I SAN JOAQUIN LOCAL HEALTH DISTRICT ` j t 1601 E.Ha:ellen Ave. 300 West-Oak.S rear 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVMCO S•S9 3M 3-'63 F.P.CC.