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t FOROFFICE USE: ap ----------------------------------- ------------- -------------- -------------------------- --------------- ------------_________________________________________________________ APPLICATION FOR SANITATION PERMIT Permit No. ...�. ..'1`�_ (Complete in Duplicate) I ---------------'----'- ------��---�--.--=---------=-- To Permit Ez ties 1 Year-From Date Issued 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 OCATION- .,_lr,�. ✓4 ?- - --- / , � Owners Name ` ' GTT '• - - -•---.Phone �� . O Address -------- ---- r�-------- -----------------------------------------------•----------------------------------------------------- Contractor's Name------••--- ---------------------- _ Phone..._................_.............. Installation will serve: }Residence Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/-___ Number of bedrooms -;Z- Num;�� fhe _/__ Lot size � � ------------- Water Water Supply: Public.system ❑ Community system E] Private to WaterTable_fit.' Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sand Loam ❑ Clay Loam (] Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes date___________________J No & New Construction. Yes ge-go (] FHA/VA: Yesg?"No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permiffed if public seer is available within 200 feet.) Septic Ta k: Distance from nearest well_/4 Distance rom f undation----I�-:-_-_.Material___- No. of compart1 encs.__. - size-,I _ -_- -_-Liquid depth__..__ ..ZZ l Capacity--- .___�Q-- �- _ � ' Disposal F• Id: 'Distance from nearest well./_A_k5_._Distance from foundation_a Z---------Distance to nearest lot ine_Le-----___.. Len th of each line_____ Number of lines'___/--------- g "_______________Width of trench___.--------------- -__.--.___ r`- ' liC 9 / Type of filter material _" Q __ Depth of filter material ------Total length_--- . -------------------------- I V/ 1 Seepag it: Distance to nearest-well---1,2,'._-____Distance f,ro foundation_. Distance to nearest lot iine__s.y�_-".- Number of pits_`- --------------Lining material___,—V;,eSize: Diameter----- ...........Depth---�T�.�__*---______ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- Size: ________- Size: Diameter- --- ------------------------------Depth--- ----- ------------------------------------------Liquid Capacity----------------------------gals. '- .--=.=-P'riv "" -- Distance from'nearest`well_____________ __:--------------D'istance from Aearesfi buildin T ❑ Distance to nearest lot line" ----~---------------------- ------- ------------------------ Remodeling -------- -----------Remodeling and/or repairing (describe):------- -- ------------------------------------------------------- --•- - - --------------------------- i t ---------- ---------------- ------- ----- ----------------------------------------------- ---.---------------------------------------------------------------------------------------------------------------- I-hereby certify that I have prepared this application and that the-work will be dont in accordance with San Joaquin County ordinances, State laws, and ales and regulations of theSan Joaquin Local Health District. f f (Signed)------------------ ice/;ielattion ---------' -----' or Contractor] By ..... ......----------------------------- -- •--- � ..(Tit le)------�•fJZG2.lG. ---------------- (Plot plan, showing size of lot, location of system to wells, buildings, etc., can be placed on reverse side). OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- ------------------ '— - �� " -- --DAT1_-._ -----------• ------------ -------------------------- REVIEWED BY --------------------- - ----- ---- `-------------------- DATE-------- BUILDING PERMIT ISSUED -------- ------- --- '� N- DATE _ .__ Alterations and/or recommendations_________________ ---=------------ - -- ----- ----- ------`-=-- -------•-•--------------------------------------- ... - ------------ ------------------------- ------------------- ---------------------- ---- ----- `•-•------•------------•------•------- ------------ ----------' FINAL INSPECTION BY: - --------------------------=--------- Date. : f..__�.. .. I r , t SAN JOAQUIN LOCAL HEALTH DISTINCT 130 South American Street 300 West Oak Street��` 124 Sycamore Street 1 * 205 West 9!h Street J _ a Stocktonr California Lodi,California 4 `Mantecd}California r Tracy,California ES-9 REYI9ED 13.69 r.P.CD,210 6-60