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FOR OFF. E U�: r ----- 1221. APPLICATION FOR SANITATION PERMIT Permit No. ._ 3../. _...s (Complete in Duplicate) ---------------------------------------------------- --- This Permit 'Expires 1 Year From Date Issued` Date Issued ----� Application is hereby made to the San Joaquin Local Healfh District' 6 a permit to construct and install the work herein described. This application is made in compliance with County Ordina ce No•1. 544 ` � JOB ADDRESS'AND C ION-_..•�? - ! - ! -----------------------------------------------------------------••--------------•---• .. Owner's Name-- �y� ------- -•-----=--------- •-------•--------- ---- Phone----------....-.........------------ Address---------- f � --------'!...----.. .......... •---------------- -------•-•---•------------------------------.----- Contractor's Name----------- ---. Phone......................... rs Installation will serve: Residence 2--`Apartment House ❑ Commercial• ❑ Trailer Court ❑ Motel ❑ Other. ❑ Number of living units: __/___ umber of bedrooms __, •Number of,baths _,/--- Lot-size _r / _f-------------------------------- Water Supply: Public sys*em Community system ❑ Private ❑ '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•;. pp (If --------------------- � y ,dateI No 0 New:Construction: Yes E] No WFHANA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank o?,cesspoolpermitted,if public sewer is available within 260 feet.) ! _ r 1 f Septic Tan Distance, from nearest well. -----_Distance from- founclation---_X�---__--.M t �aL- -_lr- _- ------- No. of } Liquid de / ------ ----Capacity- 4$ ---/-- -- Qisp�Lo!!s/aField: Distance fromne.arest well .F � Dista nceffrom; foundation..... ....Distance to nearest lot line— --___-- ub4 a Length#of each line___ � - Width of trench t ` . . � - _ -------------------- Type of filter rimaferialf -- al--- length___-De th of ye -------------------------- Seepage -_Seepage it: Distance to ne rest:wel _.__r_�`---Distance�.from foundation___��___�----.Distance to nearest lot line-_�------ Number of 1?itas - _- ____Lining material_� ( --Size: Diameter, -------------Depth-- �- �i ..t �: .t :_..r-r/ Cesspool: Distance from nearest well_-a-------------Distance from foundation-- -----------------Lining material-----------_-----------------_----_-. Size: Diameter--- ------------------- -------------.-De th--------------------- ---------------------- Liquid Capacity gals. Privy: Distance from nearesf well-' _ -------------------------------------Distance from nearest building.-_--------------------------------.------. ❑ - Distance to nearest lot line---------------------------------------------------r' " Remodeling and/or repairing (describe):------ °: ------- �r --- ---- • •- ---------r---•---------------•.----•-••------- , t r -----•----•------•------•-----------------------------------•--- ».- t ---------------------------------------------------- -------------------------=•------------•-------•-------------•-•--j----.---•-.--------------------------------------- ------------------------------------------ . a y'certify that I have prepared this"application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rul s and regulati ns of the:,San Joaquin Local'Health District. St ned "�T ( ig )------------------------- ---------------•---------------------------- or Contractor] --- t By:-------------- ------------------------ ------------------ ' --- -- --;�--_----------(Title)---- - r---- ----------------------- (Plot plan, showing size of loft, location of syst to relation. wells, uildings, etc., can.be place- d on reverse side). JL FOR.DE:PARTMENT USE ONLY APPLICATION ACCEPTED BY - - - t=` ------------------------=--- ---------------------------------------- DATE---------t J�. __ L 1 '` REVIEWED BY------- ------------------�--------- -- --------------------------------------------------=-----------------------------•--- DATE----• •------........ . BUILDING PERMIT ISSUED = =•--••------------- :------------------•-------------- DATE------------------------------------------------------------- Alterations and/or recommendations_-- i--------------=--------------- ---------------•-••--•-----•----------•••-•------•------••---•--•-------•--•-•-----•-------•----------• •--••------------- t -------------------------------------------------------------------------------------------- ---------•---------------•--------=-----•---•------------------- ----------------------•-----=--------------------------------------------------------------------------------------------=----------------------------•--•----------'------------------------- •-•--- ------••-•-------•-----------------=-------•------•----_----------.----.------•--•------__---------------------------------------------------------------------- r _r L FINAL INSPECTION BY:--- --- --- = ----- _ Date--•--------.44-1//1 - I SAN'JOAQUIN LOCAL-HEALTHDISTRICT j 130 South American Street 300 West oak Street , ,.)..124 Sycamore Street 205 West 9th street Stockton, California6 r 60 Lodi,California Manteca,California ,,0 Tracy, California ee-9 RCVi9ED