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FQKQI`H(�E USE: -------------- APPLICATION FOR .SANITATION PERMIT Permit No. _4/,x_3...�7 -- - ------------ -------------------------------------------------- (Complete in Duplicate) 11, Date Issued -------------------------------------------------------7 This Permit-Expires I Year From 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. 01 JOB ADDRESS AND LOCATION...$.'�39e.W __,9e4,11Wr dy,!'c-- --------------------------------------------fW--------- --- .......... ---------------------- .............................. Owner's Name----- %%------- ------ Phone...... Address------------574' *F e, - ---------- - ------------ -------------- .....................................................------------------------------7---------------- Contractor's Name-------------- ......... ------------------------I--------------- ----------------- ------ --------- Phone. Installation will serve: Residence 'A Commercial:, E] Trailer Court ❑ Motel 0 Other 'Apartment House F]�o Cbmmerr or Number of living units: Number of bedrooms Number of baths Lot slie ---/_Pjo .. .................... Water Supply: Publi� systeniA"g? Comm6rYity system El iPriv`ate El Depth to,water Table 450 ft. Character of soil to a.do,pth of 3 feet: Sand C] Gravel ❑ Sandy LoSm El Clay Loam 0 CI Adobe Erlardpan 0 0. ay Previous Application Made: ((If yes,dote_____ _ - ---------) No.Bl-' NewlConstruction: Yes E] No [B� FHA/VA-. Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank orycesspool permitted if public sewee,s available within Y(Q feet.) Se.ptic.Tank. Distani:e,*'from:ne6'res+.Well.,-.-..-.-,.----Distance from foundation -----------------Material------------------------------------------------- No. of compartments--------------------------Size------------------ ------------1 Liquid depth ....................... -----------------.-Capacity Dispgsal Field: Distance from nearest well-----------------Diita `.Distance to nearest-1of line.........._...... nce from foundation..............i.. --- .-.Width of trench--__-_----------------------------- Number o 4 lines" . es....................................Length of each line---------- Type of filter material -----------------------Depth of filter material_,___�--------------\---Total length..._.....__..._..............._.........._ Seepage Pit: -Distance to nearest well---------------------Distance from foundation...11ell-1.4—Distance to nearest lot line... Number of pits_____ _____________Lining material_/CAd-r_1t:---Size: Diamd4er_.J%-.?".r_..........Depth.-,:? _. ..1........... Cesspool: Distance from nearest well-----------------Distance from foundation-------------------1ining material------------------------------------- . . _r It I 171 Size: Diameter----------------------- •-------------De pth,_- ------------------------------------------t—Liquid Capacity------------------........gals. 71 0. Privy: :Distance 'from nearest well---------------------------------------- ---------Distance from nearest building-.--.'........................... ❑ Distorid6lo-"ea rest ]of line-----------------------------------------------------------------Z:�------------------•---------•--•-•--•----•-------•-••----• ---------- Remodeling and/or repairing"(describe): ----------- ... ... -------------------------------------------------------- ------------- --------------------------------------------------L................................................................................ ---------------------------------------------- ----------------------------------------- --------------------------------------------........................-------------- .....................................................--------•---------------•----- ----------------••-------- I ---------------I------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that'+he work will be done in'accordance with San Joaquin County ordinances, State laws, and r'u'les and regulations of the San Joaquin Local Health District. (Signed)------------------- I'--------• -"`-=-`-'---•--•--_------- (0wneF=wvcVor Contractor) BY-------------------------------------------------------------------- --------------(Til t , - ------ 4.-- _t -1#__�_------/*-I-;*___ I--- ------------------------------- (Plot plan, showing size of lot;'location of syste�n relation to wells, buildings, etc., can be Placed on reverse side). *_FOR-DEPARTMENT USE ONLY APPLICATION ACCEPTED BY. _.-•--g ...9___712 REVIEWEDBY------------------------11----------------- -------------------- ------------............................................... DATE-------------------------------------------- --------------- BUILDINGPERMIT ISSUED__A-------------------------------------------------------------------------------------------------- DATE------------------------_-- ------------------------------- Alter fions jind/oi recom en tions------------- ----------------------- ------ ------- ---- -- -- ------ -- ---- ------:2----- ....... ---------------- ------------------------------- --------------------------------- ........................ --- ---------------------- ------------- ...... /V w ---- ------------- ----------------- ------------------- ------------------------------------ ------ ------------------------- _A FINALINSPECTION BY------------------- --------------------------------------------- Date------ ---------------------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West 01k St� 124 Sra! or*;Street 205 West 9th Street Stockton,California Lodi,California' tMantsica,-Callf&r.10, Tracy,California ES 9 ItEVISM 5-59 VM 5-61 ATLAS V