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I-UKvrrict USE: ---- +. ---- "------ -------- ---------"."__.._____---- ____- APPLICATION FOR SANITATION PERMIT Permit No. ....� �� ! ,3(Complete in Duplicate) ` ----------------------------------- # This Permit Ex fres 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 h rein descrbed. This applicafion is made in compliance with County Ordinance No. 549. ��CH JOB ADDRESS AND LOCAT ON.._.__4 Owner's Name---------- ' I -�- f P u`-• - - --PF" -----��1_x -a�--------it ----- ---- ----- ---`------------- •--•-- r� A;-.-1------------- ---- ------------- PhoneAddress . = - - s TOC . � • ••- ---------•--- ----.. Contractor's -------------------------- ----------._ Phone. Installation will serve: .Residence ❑ Apartment House ❑ Commercial � ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of.living units: __ __ Number of bedroom's �. ' ______ Number of baths -_______ Lot size -----__________ Wa#er Supply: .Public system -----=--------------•------------------------ Y ❑. .F ommunity system ❑ Private [�DBpth�fo Wafer Table 3 #f. ' Character of soil to a depth of 3 feet:..Sand-�Gr:avel,{I.Sand.y Loam ❑ la'. Loam❑ Clay Previous Application Made: (If yes,date_______-- =. � Y ❑ Adobe ❑ Hardpan ❑ t ¢ � 1 No New Construction: Yes I� No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPEC IFICATIONS..At.1,A3W (No septic tank or cesspool p;r fitted ifspublic sewer is available within 200 feet Septic Tank: Distance from nearest well___®"" , :> Distance from foundation_ --- "" ----Maieriai--COI�:G�� r �, _ ...,. -i af-compartments----"----- -------=---- -Size- a_ XS"_K--3-Liquid depth---5_ - - :-- " Ca acit J�00.__. p� Number i ` .. p Y- from nearest weil___�-�t�-_ Vi` foundation __Distance to nearest lot fine________•-"._-""_ is osal Field: Distance of lines!_"",___.�---------__Length of each line_."S"��` 'C� r M ,� { `3.7- -Width of trench--- -�- �--------------- ype of filter material___ "C(GJt:_-"Depth.of filtem�ferial_____L -_-_________Total length____________6.1�___________________ Seepage Pifi: Distanceto nearest well ________ _____ Distance from foundation-------_------------Distance to nearest lot line_-___-_.___.__.. ❑ Number,of pits-__1___---------------Lining material---- .,_____N.Size: Diameter__"----------- i Cesspool: Distance from nearest well------------------Distance from f"oundation ,=l,-...�L'iFiing material-----_._ ❑ Size: Diameter.-=- ./ - ------------------------------Depth---- -------------------------;k ----------------Liquid Capacity- 9afs. 1I Privy: Distance from, !.est well_"___._-- ______ --__"_____________________ "_Distance .from nearest bui!ding---------------- Distance "_"""___- ❑ 'fo nearest lot line --.--"_- " ---- -- �T+ - __ _________ ________ _ , Remodeling and/or repairing (desscrih):------_--,"F------------- ---_- -" - if. a _.,. - -------------------------------------------------- -- ------------- rte►}�1 mer+ i ----------------------------------- .; -•----- --- ---------- - ' = t' w ,t s -------------- - -- -------=---=----------------------"-------------- ' I hereby certify that i have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules an .regulIns of the "n Joaquin Local Health.District.' , v { :._ji f (Signed)- __k T i I . ----------------------------------- - ------- -- ----------------(Owner and/or Contractor) 'By:------------------------- I'-- ----------------- f 9 [Title) ---------- ------ ---------- ----- -, _ ____ ___ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc.i can be placed on reverse side). FOR DEPARTMENT USE ONLY; • APPLICATION ACCEPTED BY____-- .J:._ N _. DATA±-------�'�!•�'L--'�-` � .: * REVII=WED BY -= ----- � ____ -- _ DATE BUILDING PERMIT ISSUED--------------- -- ,.., _ _ --- -___- - --- DATE------------------- A Alterations and/or recommendations:._ T ------ L .. - ----- ---------------------.----------- -------------------------- ------------ ----------------- . FINAL INSPECTIO - - ----- - -� Date _.- --,�$.._ I .. . .e----------------------- SAN ------ --- --- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 724 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California iwS 9 REVlS Ep B-S9 3M 3-'63 F�P.CO.