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FOR OFFICE USE: lob "1 APPLICATION FOR SANITATION PERMIT Permit No. 11?y-20r ---------------------------------------- --------------------------------------------------------- (Complete in Duplicate) Date Issued --- -------------------------------------- IThis 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. JOB ADDRESS AND LOCATION ------A-1_R_PQ_[3T_____WA_y___-___300-------/V__er____-_�ATH.I�Q_�-'____�-I? . Owner's Name-----------------E-L-909-19-------SM-—T ------------------------ -------------------------------_---------- Phone------------------------------------ E ----_---------------------- --� � x -- � � --------------------------------------------------------------------------------------------- Address--------------------� -- ------ - --- ----- ------ - ------- ----------------- Contractor's Name--------C,4J:t6_1_tX--- -------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence f7�Apartment House ❑ Commercial ❑ Trailer Court ❑ M tel ❑ Other ❑ Number of living units: -_I---- Number of bedrooms A*---- Number of baths --{--_ Lot size ___________________________________ Water Supply: Public system ❑ Community syst m El Private R Depth to Water Table __ ft. Character of soil to a depth of 3 feet: Sand [Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No e New Construction: Yes ❑ No DR1"`FHA/VA: Yes ❑ No )� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank- Distance from nearest well_________________Distance from foundation--------------------Material______-_____--__-___________________--____------ f)OGT(ff - No. of compartments-- ----------------------Size--------------------------------Liquid depth------ -------------------Capacity----------------------- Disposal F' Id: Distance from nearest well----50----Distance from foundatio 119 --- to nearest lot li e-- Number of lines--------I _______-_i----- --Length of each line-------- _�__- Width of trench trench______- ------ ----------------------------- ---__ ___ _ -_____ ._ /-Q---_-_-_-_-_-�--_- _-_ _- _-_ ___ Total length of filter material of filter material Seepage Pit: Distance to nearest well-------.--------------Distance from foundation___________________.Distance to nearest lot line-----.____-_____- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------.----------Depth____-_-___-____________________ 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------------------------------------------ 0 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 ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. Ct�Gr --G�Li------------------------------------ --------- --------- ----------- -----------------------.-(Owner and/or Contractor (Signed) �^ By:--------------------------------------------------------------------------------------------------------------- -------------------(Title)----------------------------------------- -- ---- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY / APPLICATION ACCEPTED BY --• --------------------------- --- ---------------------------------------- DATE----- 7 G-_ ------------ REVIEWEDBY------------------------------------------------------------------- ----------------------------- -------------------------- DATE------ ----------------------------------------------------- BUILDINGPERMIT ISSUED----------------------- ----------------------------------------------------------------------------- DATE------------------------------------------------------------ Alterationsand/or recommendations:------------ - -------------- --------------------------------- --------------------------------------------- ------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------ ---------- -------------------------------------------------------------------------------_ ----------------------------------- --------------------------------- ---------------------------___----------------1----- --------------------------------------------------------------- - -------- -------------------- -------------------------------------------- ---------------------------------------------------------------------------- - FINAL INSPECTI Y. ----- Date------------- 77-4�S� -------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CO.