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FOR OFFICE USF: -------------- ----------- --- ---- - ry APPLICATION FOR SANITATION PERMIT Permit No. 5� - (Complete•in Duplicate) Date Issued -_-,._--.----____----____----------_--.--________-- -.- This Permit Expires 1 Year From Date Issued fir Application is hereby made to the San Joaquin Local Health;D.istrict for a permit to construct and install the workherein described. This application is made in compliance with County Ordinanae=.No. S49. J08 ADDRESS AND LOCATION -O F_ V 1 �0 I14N_TE ' Owner's Name -- ----------FrVI-15-M----------- --------------------------- -- ----------- --------- Phone-_'F-___.----------------------- Address__ f 4 UU /-'meg---�-•--------------A T '--------------- ------------ �' -----------------------•-- __________' __________ - F ;- -__ Contractor's Name__.------- I [� - ----- _ . - °!-------------------------- -- ------------------------ ---------------------- Phone-•-=' ------------------------- Installation will serve: Residence Er Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ____ Number of bedrooms _ = Number of baths./------ Lot size _____________________ I Water Supply: Public system ❑ Community system ❑ Private g'Septh fo Water Table' _ ft Character of soil to a depth of 3 feet- Sand [Gravel ❑ ',Sandy Loam,❑- qIq Loam-❑ ' Clay ❑ Ado6e ❑ Hardpan.❑ J --1 Previous Application.Made: {If yes,date.--.-------------.. 1 No New Consfru�ction � iYes ❑ No k� 3?FHA/VA: Yes ❑ N - ..1,- !a IFI:11 •�-� TYPE OF INSTALLATION AND'-SPECIFICATIONS: 1 # �--_[No-septic -tank or cesspool-pe�rrli++edrif public sevrer is`available wi+fiin`200 feet.) tet" w Septic Tank: Distance from nearest'well-----------------Distance from foundation- ---.--_.Materia, -----I,--------- '_-_ _____-_____--____--____. No. of compartments. .............Size-- Liquid depth ; ;L. .CapacifY---------------------- - Disposal Field: Distance from nearest well___.- AO__-_Distance from foundation___-_- Distance to nearest lot line Number of lines-----------] --------Length of each line__ __ ! -_ ___ ...Width o�trench _ . . Type of filter material-___ ' ):�_ .__Depth of filter material�"� ' :._:Tota Iength _______________ Vel ; ' -- Seepage Pit: Distance to nearest well. ..................Distance from foundation -- -____-__.Distanceoto nearest lot line----------------- El . _ -__--____-_❑ dumber of pits--- ------------------Lining material---------------------- Size: Diameter------------------- ---Depth-'------------------------------- ❑ Size: Diameter- -_ - Depth---------------------------------------------------Liquid Capaci y- -------------------------- Cesspool: Distance from nearest well ----------------Distance from foundation._.._-____._..... ..Lining material-__- 7 -• gals. Privy: Distance from nearest well.----_____.......... -----------------------------Distance from nearest bui#ding----------------------------..___-.____. ❑ Distance to nearest lot fine ---------------------- -- --------------------------------••------------------------- ' S F-,----------! Remodeling and/or repairing (describe):-------- - -------- --------------------------------------------------------------` -------- ------------•---------------- - ----------------------------- ----------------- ---------------- ---------------'--------------------------- ----------•----------------------------------------------------------------------------------------------------------------------------•--- --- I 1 ----------------------------- - ---------------------- -------- ------------------------------------------------------------------------------- ------- I 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. i [Signed} - - ----------------- ------------------------ wrier and/or Contractor) Y - -- - •-- - --- --(Tit a}7 --T -=--- - - ------------_ -- -- [Plot plan, owing siz f lot, location of sys+em in relation to wells, buildings, etc., can be placed on' reverse side).�� FOR DEPARTMENT USE ONLY t APPLICATION ACCEPTED BY-------` ------------------------------------------ ---- DATE-------- 0----- ,K-.--�'�� ;----------- - REVIEWEDBY----- ------ ------------------------------- -_-------------------- -.- - •---------------------------------------. ----- DATE---------------------------i BUILDINGPERMIT ISSUED-------- ------------------------------ ------------------------------------------------------------- DATE------------------------------I------------------------------ Alterations and/or recommendations---------------- ------ I : ------------- --------------------- --- -- -- - - --- ------- --------------------- ----------------t , ----------------------•------- . ................. ----- - --- - - ----- ------------ - - ------- - ------------------------ ------------------ ............................................ FINAL INSPECTION BY: Date------------- r. -C -,7..- ---------------------------.-_ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 6,Hazellon Ave. 300.West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi. California Manteca,California Tracy,California pL E-H.9 2M 1.67 Vanguard Press 4