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rUx VrI-K-t USE: -------_------------------- ------------ - ----------- '" -------- APPLICATION FOR SANITATION PERMIT Permit No. 3 ----------------------------------------- ------- (Complete in Duplicate), ` This Permit Ex ices 1 Year From Date Issued ----------------- ---------------- ------------- Date Issue Application is hereby m235--fiv-- b0-5Thiade to the San Joaquin Local Health District for a permit to construct and install the work herein described. s application is made in compliance with County Ordinance Ko. 549. ' JOB ADDRESS AND LOCATION__,$ u�f � , 5 �1�r yr�G� ,1� ------- ! ' �`'� J' `------------------` ' Owner's"Name_---_ '"' �=o Phone Address ---•---------• ----- Contractor's Name _ -------•--• 1�,-------- ----------------------------- ------ --------------. Phone------••-• � • Installation will serve: Residence E] partment House 1-1Commercial ❑ Trailer Court ❑- Motel ❑ Other �� "Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size 1 Water. Supply: Public system El Community system ❑ Private d Depth to Water Table ? ft. Character of soil to a depth of 3 feet:-Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay E] Adobe ❑ Hardpan Previous Application Made: (If yes,date--- --------) No J New Construction: Yes �No ElFHA/VA: Yes E] No TYPE OF INSTALLATION AND SPECIFICATIONS: �/ `� (No septic tank'or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest wed-.3 Distanto foundation----/P----------Mat rial----- __ No. of compartments_______ __________"_..__Size-h'A �---- -�• •---X-• -- �Liqu�d depth----- .�" Disposal Field: Distance from nearest well--------------__'Distance from foundation"""__"_"""" "_---.Distance to nearest lot fine__----_---__--_- j ❑ Number of lines ------ Length of each line------------------------------Width of trench----------_-_--- Type of filter material-------------------------Depth of filter. material----_-----------------Total length------------------------------------------ Seepage ---------_------_-- ------------------- N r / Seepage Pit: Distance to nearest'well___J67-0 """Distance from found an__." I 1 L. ____-__-Distance to nearest lot line-"---- Number of pitst, g matetiaL Z�(�� - +z�erD fh J ;_ �--� � � Cesspool: Distance from nearest well inin A _":Distance from foundation_________"_ ming aterial l --- ` ❑ Size: Diameter } ---- - ----- ----- Qepth --- ------- -Liqu-d Capacity, - T- - - Privy -Distance from:nearest well "'` gals. _ _ 1 —�� _ �� '"r-""'y ��"'"Distance fiom'neal'esfi�lluild�R�_____ __�_______�___"__ __"_"__'_�_`_'_"^___` ---- --- --- - ----- ❑ Distance to nearest lot line.-.." -_ g ----`-- �f----------""------------------------------------ klltx Remodeling cl/or repairin (de-s�cri-be):- "ss.__ �/C ' •-- �!! �f f'-r-,'f es � =,-' ------------ � ----------------- =' I hereby certify that I have prepared this application and that the work will be done in acco ante rf th San Joaquin County ordinances, State laws, andrules and regulations of the'San Joaquin Local Health District. 77 Y (Signed)_" ---- tom'-�-------------------- ---------- ---------- •-- --- -�.�"-- �?-- • ---------"""--- -- -.---(Owner and/or Contractor) , By:---------------------------------------------- ---------------------------------------=------ (Title)----------- ------------------------(Tit __ ------- (Plot plan, showing size of lot, location of system in relation to wells, buildings,-etc., can be placed on reverse side). .. t , FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED.By----------- _"""-___-___ DATE ---------------------------------•--------------- { REVIEWEDBY---------------------------------------'------------: --- ------------------------------------------------------------- -. DATE-" '- -- - --- � BUILDING PERMIT ISSUED----------------------------------------- i --------------------------------------------•_------ . DATE----------- Alterations _-=-----�- - and/or recommendations------------- - - • _ �- ------------------------------------------------"---------- -----------'......-----------------------------------"-------------------------------------------- r ----------------------------- .-____--"--...._.-".".-_-___ r -------------------- FINAL. INSPECTION BY________ _ _ ' r ! Date - 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ha=ellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California FS 9 REVISED 6-59 3M 3-'63 F.P.CC.