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q 1 r FFICE� USE: 1% m. , r ---------- s•- ------------_:_w_. --------- APPLICATION FOR SANITATION PERMIT Permit No. { ---------------------------------------- --------------- t (Complete in Duplicate) - This Permit Ex fres i Year From Date Issued Date Issued Applicafion is hereby made to the San:""o'a'-quin 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. - J JOB ADDRESS AND OCATION__{._ ------------- ---- -_ - ----------_-----------------• ----------------------------------------------------- - ---- - Owner's Name--- ------------------------------------------- --- Phone-----��-- ` / - Address----------------- •---�flP�.�� ----------------------- ------------ ------- ----- - - - t_1------------------------ --------------- Contractor's Name----- � t ---------------------------------------- -----•-•-----•-•-------•- - - ---------------- Phone----••--••------•-------•-- nstallation will serve: 'Residence [LYApartmen.t'<House-,❑_ Commercial ❑ Trailer Court ❑ Motel [� Other ❑ Number.of livin" units.--_Lt_ g ! ___ Number of bedrooms __ Number of bath`s ___�__ Lot siie Water Supply: Public system gErCcrnmun€ s stem tY y ❑ Private ❑ Depth to Water Table _�s5__ ft- Cha t. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay El Adobe ❑ a Previous Application Made: (If yes,date_.._-_._"' __--____.J No /It$ pew-Construction: Yes IrJ iso ❑ FHA/VA: Yes ❑ No [��'`- TYPE OF INSTALLATION AND SPECIFICATIONS: : ` (No septic tank or cesspool pe'rmi+ted if public sewer is available within-200 feet.) � . Septic Tank: Disfance\from nearest well'-��__Distance from foun`dation______ Material_- Cj" As ----------------��--------- � No. of compo; en's_.'' -,�--------Size__>3.tC-sS---X--17-------.Liquid depth------_/1 --------Caacit -•--- P Y - 7. I Disposal Field: Distance from nearest well_i j---h� Distance from foundation------!�--------Distance to nearest lot line___6--_-- J --- �------- -.Length of each line-----------.7C�--- Width of trench-----:----�T-__---•--------- Number of lines._____.______'- � '"`� Type.of.filter material.,S�ex _`� U Dep#h of;filter matetial � ------?-----Total length__-_________ -------------- 7. �C2- Seepage Pit: Distance to nearer# well___.A,Q , #Distance fr rn-fo'undafion 1%46- e ._Distance'to nearest lot hne__.`5---- -_ _ [l Number of pifs---------f:-._____Liriin material.-_ -----Size: Diameter------a?3 ,'---,_De th-------_-- r -- Cesspool: Distance from nearest wei€-____________-_ ` "i I W � S _Distance from.foundation.--__ .___-.____-Lining materia!__"~----------------- ------------------- ___----.-_--:- ❑ Size: Diameter- ---- -- ---Depth------ Liquid Capacity *-gals. ------- Pri,vy: Distance from nearest well -`_"3V':--_t ___ pistanc'e from nearest building It F [f 4Distance to nearest ,Iot line------------------- - `.�" . - -------- ------- - ------------ ---- Remodeling and/6r repairing (describe)--------------- %.,_U r -# ------------ _ --•-------•-•----•--------•--------------------- ----- �r ----- ------=- - .. -------------------- ---------- _ = - IN _ _______________________________________._._______________________ ------------------------______________________________________ _ _ ! hereb certif that 1 have y y prepared this application and that theTwork will.be done in accordance with Sari Joaquin County ordinances, to laws, and rules and �egulafions of the San Joaquin Local Health.District. T €i (Signed) ^-�°y y ------------ -------------------- --------------------------- - = � . - - -- caner and/or Contractor) Y= ----------------- ---------------------------------------------------------(Title)------------------------------- --------: -------------------- (Plot plan, showing size of lot, location t f system in relation to wells, buildings, etc., can be placed on reverse.side). ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_____________ _ ____- _ T - - --� -------------- DATEREVIEWED BY ! t -------------- -- ------- -- -------------------- - -------------- - BUILDING PERMIT.ISSIJED-----^ DA ---- ---• ------------- - -------------• -- DAT --------sand or recam endo ions:_ 2 - �Y f ---- --------------------- -----------------=---------- -------------------------------- ------------------------------------------------ -------------- t ------------------------------ ----------- '------- - y ---}---------- t w '+c r FINAL INSPECTION BY:------- G-d �s-, 4 Date - -�� —... } �`-....-n ------------ ---------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th 5treet Stockton,California Lodi,California Manteca,California Tracy,California i ES 9 REVISED 0-59 3M 3••63 F.P.q O. •'' �'�