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I-UKU�WIE USE: ` �?--------- 1 - f�� :. -- �----- APPLICATION FOR SANITATION PERMIT Permit No. _ -------------------------------------------------- (Complete in Duplicate) .... Date Issued --------------------------- - This Permit Expires 1 Year From Date Issued Application is hereby made to fhe San Joaquin Local Health Distric# for a permit to construct and install the work herein descri r This application is made in compliance with County Ordinance No. 544. bed. 'JOB ADDRESS ND LOCATION..__ --""_hl) 74 t --------------•----------------------- ------- - I Owner's Name- a .. --------- - ----- ---------- -- -- Address ------- .rd�Cl r_ ------- Contractor's N r ame__ t c-� """"""DD` k ---1-f ` ° ----•---- Phone/5-0-jus Installation will serve: Residence par Atment House ❑ Commercial ❑ Trailer Court f ❑ el ❑ ;�� Number of living units: ___ Number of bedrooms :!Number of baths A �' --- Lot size . _ 00, Water Supply: Public system Community system ❑ Private /7-/Oft.//�� f ❑ Depth to Water Table`7"vft. Character of soil to a depth of 3 feet: Sand Gravel [] Sandy Loam ❑ Clay Loam [] Clay ❑ Adobe 0-'-Hardpan C] j Previous Application Made: (if yes,date ) No F1 New Construction: Yes El No FHA VA: Yes C TYPE OF INSTALLATION AND SPECIFIC T ON�? R El No E] (No septic tank or cesspool permitted if public sewer is available within 200 feet.) n Septic"Tank: Distance from nearest well_144_)L_;-_ -rDistanceffrom found on__ ` _ /` . �r Material-i----------- ---------- •_ ��'�-� No, of com artments___4�_ .__Size_ e_ ____ r Dis sal F' Distance from nearest weft. 0 - Liquid depth---- _ ----_----Capacity___7- �7: ' ' Distance from foundatio __ - ____.Distance to nearest .lot )ine._____."___ Number of lines-----------------------------------Length of each line--------------- Type of filter material____ -_-------------1/�idth of trench------E____" --------- y --------------- ----'----------------Depth of filter material------------ -------Total length-_-------------------:---- Seepage Pit: Distance to nearest,well�A:e`3uL,J--Distance om foundation___ 1r.___..._._.Distance'to nearest lot line__---. -- " Number of pits j___---_.-___-- Lining material_- p_ �undation Size: Diameter_---`�� Depth- - � �!---- ---•--Cesspool: Distance from nearest well_______________`__ Distance from ____________________Lining material----_--___._____..____"__.- ----- El Size: Diameter. Depth ----------------------Liquid Capacity----------------------------gals. Privy: , Distance fromnearest well--------_____.+ _____ -------_.____-___-__Distance.from nearest building`�- g a ❑ Distance to nearest lot line______._._.__"_-_"___- - � i ----------------------------------------- -- J Remo eling and/or rep 'ring {describe)'_-- -" - p� - -------- 4k` a --------------------------- -------------------------- ------•-----------------------•------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County i` ordinances, a la and rtkies and regulations of the San oaquin Local Health District, 1 (Signed)._. =-------- - ------------------------------------ --- e�r Contractor) By: -------- ------------------ ---------------------------- - ---- (Title) ------- ---------------- ---------------- - (Plot plan, showing size of lot, location of system in Tela an to wells, buil ngs, etc., can be placed on reverse side). F DEPARTM>=NT USE ONLY i APPLICATION ACCEPTED BY___________ ___ __ ' ------- DATE 1 � '-------- ------------------------------------ REVIE WED BY -------- - ------ - DATE----- m BUILDING PERMIT ISSUED---------------------- ----------_--------------------------------------------------m- ------------- DATE A)fer,**ns nd/or ecommendations:__----..-".___.__...____'. t -•------- - ------- --------------------------------- ------ ----------- ---_- - ----_ ------------- � � __ --- ------ ------- --------------------------------------- - f - r ,. = •-71��------a•� �-- . ----------- -------- ----- - -- - ------- -----a _ "S FI . Date: - -- # - r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazel'ton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California JTracy,California odi,California Manteca,California t EB 9 REVISED Q-59 3M 3-'63 F.p.CO. f