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FOR OFFICE USE: / �, f, . } ------------------ -- --- APPLICATION FOR SANITATION PERMIT Permit Na. ____.='.. .....G .: -------------------------------------------------------- (Complete in Duplicate) -------------------- ---------- fJ r ------------------------------------------ ------------- This Permit Expires 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. S49. JOB ADDRESS AND OCATION__`Y_ �c .----�-Lo --0G.-----,� .4_��Ay-l1/ ... ..........------------ Owner's Name-----MAl-, 4[ ----------------------------•----------------------- ,}------------------------•------------------ Phone-----------•--•--------------------- ' Address --- .e ' '------------------- -------- --•-----•----------------------------•------------------------------- Contractor's Name----0-Wet—n t------- ------------------••-•----•--------- •--------------------------• ------------------------------------------------ Installation ------------------•-------------------•-------Installation will serve: Residence M Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .-_ _-_ Number of bedrooms -0...... .Number of baths A", Lot size--------------•.:------__-----.---------_-------_-----__-_-.- Water Supply: Public system ® Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam,❑ Clay Loam ❑ Clay ❑ Adobe® Hardpan Previous Application Made: (If yes,date--- ----------------) No ❑ New Construction-: Yes-®.MNo.,❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: I I I (No septic tank or cesspool permitted if public sewer-is-available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation_'/_Q ------Material----4P-c_�V.#O '___________________. No. of compartments_..._.oZ�^------.--Si. _,_-K_F_jXLS-----------Liquid depth......YL.2--------------Capacity.... Disposal Field: Distance from nearest well-----------------Distance from,foundation....f `_------.Distance to'nearest lot.line..... �_..... Number of lines___-------12-11".___.-_--_-_--_Length of each line_14 •-/®KNidth of trench--------- -------------------- Type of filter material .....f /rm 4G _---_--Depth of filter aterial__ length--------e.. d_______________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to'nearest lot line---------_-_-_-__ rr� ❑ Number of pits----------------------Lining material-.---------------------Size: Diameter-----------------------Depth-----------------_-------- - Cesspool: Distance from nearest well--------------_.Distance from foundation----_.--------------Lining material--------.-_---_---------------_....:.. ❑ Size: Diameter-------- ----------------------------Dept h!----------------------------------------------------Liquid Capacity............................gals. Priv Distance from nearest well--------------------------_-_-----.._---_--.-_--Distance from nearest building-------------------------.---------------- . Distance to nearest lot line---------------------- ---------------------------------------------- ---------------•---------•----- -------------•-••-------- ----------- Remodeling and/or repairing (describe)--------- ------------------------------------•- ------------------------------------------------------------•--..-..---•---------------- --•-- t � --------------------------------------------------------=--------------------------------------=-------- ---------------------------------------------------------------------.............--------------------------------- i I hereby certify that I have prepared this application and that the work will 6e done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. ` (Signed): V- ---------------------------------------- ----------------------- -------(Owner and/or Contractor) By:-----------------------------------------------.------------------------------------------ -----------------------------------------(Title)---------------------------------------------------------------- (plotP Ian, ------------------------------------x(Title)---------------------------------------------------------------- (Plotplan, showing size of lot, location of system in relation to wells, buildings, etc., ceri 6e placed on reverse side). I y FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY------ r DATE lam' ---- REVIEWEDBY------------------------------- ------------ - -------------------------------------------------. DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterationsand/or recommendations:-------------------------------------------------------------------------------------------------------------------.---------_..........------...... -------- 1 ----------------- -----------.---------_.----•------------••----•------------------•- ------------ -----•-------------•---------------------------- ------•------•----- -------------••----•------------------------------------------•-------------•-------- FINAL INSPECTION BY::..----- t--- - .-. _ �-- ....-- Date------ � � �� '"�s �--------------------------------- y SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California IE8.9 NEV�gEC 9-59 i.P.0 O.2M 6-6C