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------G FOROFFIC :Y - -�� -5_.- -c- �_- P'61 APPLICATION FOR SANITATION PERMIT Permit No. ..... __ ---------------------------------------------------- (Complete in Duplicate) cI This Perrhit'Ex ires 1 Year From Date Issued Date Issued .._.___..1_,x.... 1. 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 A OCATION S_ _ ;, Owner s Name___ ___ ___ r h-�-Ld.10-1 . ----- ------------ Phone Address................... -- -------------------------- -----------•--------------•------- Contractor's Name....--•-•--••----• •----- -•------- �fl- -------------- ------------ -------•-------------------- Phone---•-------•-------_- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court [) Motel ❑ Other ❑ Number of living units. ___ . Number of bedrooms _ :Number of baths I_____ Lot size __-_ Q..._�_ �____________________ Water Supply: Public`system ❑ Community system ❑ Private DKIDepth to Water Table 4&---- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ San Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: (If yes,date____________________) No EK New Construction: Yes ❑ NoA/VA: Yes ❑ No M---- TYPE OF INSTALLATION AND SPECIFICATIONS: k (No septic tank or cesspool permitted if public sewer is available within 204 feet.)__ y Septic /Ta Distance from nearest well-----------------Distance from foundation_______________'_.Material____________.__.____________________.._----._---- ONo_ of compartments------------------------._Size--------------------------------Liquid depth- `.---------------------Capacity---------------`----- Disposal eld: Distance from nearest II-_ :Distance of each line �3__�___._.Distance to nearest lot line_ Number of lines-------------f ___ ________.Width of french--------- /__._______ Length Q�J(-6)``/i✓ Type of filter material_'�'n.�,)1�__Depth of filter material___._ __ �� Total length__________ __CC.�..._..._.._.._....____ Seepage Pit - Distance to nearest kvell---- __ _Distance from foundation_ Q._______.Distance to nearest lot line____.___. , C�� 11 . Number of pits-___i..______________Lining material--_:`�P__�._dc`Size: Diameter____ .j!____.Depth----25;Z-�r__f-_____ �y Cesspool: Distance from nearest well___T_ _4______Distance from foundation--------------------Lining material-_________-___________._____________-El �Q Y - `'.� -- =----- ------Liquid Capacity------------------------------ ---------------------------gals. Priv Distance from nearest well______.__-___---_ _ _ _______ _ __-- . Size: Diameter-------------------------- --- De th _ "`�Distance-from-nearest building .�__._.�. ❑ _. Distance to nearest lot line._._____:'_______________'___- t modeling and/or repairing (describes: --- .4 e --- _. - ------- Re ' - ----------`--------------------------------------------------------------------•----------------=----------•---------•-------------------•---------:--•-------------------------•-------------•--••----------------------•--- i f : ------------------------------------------ -------------------•--------------------------------------- -------•--------------------------------------------------•----------------•------------------------------------ I hereby certify that I have prepared th' - plication and that the work will-be"done in'accordance with San Joaquin County -ordinances, State laws, es nd req do an Joaquin Local Health District.. .. -------------------- -- --- -- -- ----------- - -- - - - - - -�! - ------------------------------------------ (Signed) --(Owner and/or Contractor) -------- Plat Ian, showing s of lot, 1 ation of system in to well `' t - {Title]___.__ __�j�� B : - - ( p g y ngs,"etc:,''C'an .be placed on reverse side). - a FOR DEPARTMENT USE ONLYAPPLICAT ' REVIEWED! BY ACCEPTED BY_ x `iC ��,..��X DATDATE 2----�--- ��{ - . f BUILDING PERMIT ISSUED-_...f:. ------------------.-------- . � DA . Alterations and/or recommendations:_ T -----------------------•-----•--•------------------ -------------------------------------------------------------------------------------------------- . -- ----- ---- -- -------------------------------------------------------••----------------- ------ -----------------------------------------------------------------------------------------------------------------------= - ---------------------------------------------------------------------- ------------------------------------------------ ---------------------........ ---------------------------------------------------------------- _ t` FINAL INSPECTION t)?( 1------ - -� � 1-_ Date-------- c _:1 - --/% jl-------------------°--. Z _ `SAN JOAQUIN:LOCAL HEALTH DISTRICT i ]30 South American Street 300 West Oak Street 1''24 Sycamore Street 205 West 9th Street I Stockton,California Lodi,California Manteca,California Tracy,California E9-9 REVI9EO 9-59 F.P.CO,ZM 6-60 -