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rult UlrKJ: USE: 'b ----7111s_ !a rv� N - - - - - Ir . __ ___ APPLICATION FOR SANITATION PERMIT Permit No. .. 7•_--. 7 I " (Complete in Duplicate) / -- --------- ---------------- This Permit Expires I Year From Date Issued Date Issued ___ 3[ 6 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. JOB ADDRESS AND LgCATiON.! --yt: _ Owner's Name___________________��'�'�'�� ----` ------ -------•---------- Phone__ --------�---�,�f� Address_____--- `y�n"--� • •---•-----•--•--------- ----------------------------------------------- Contractor's Name_~_"_e- _-[ - rf� �� i �� --------- _f- '�` `E''�' --------------- Phone Installation will serve: Residence Apartment House❑ Commercial ❑ Trailer Court ❑ Motel E] Other ❑ Number of living units: 1Number of bedrooms �� ____._ Number of baths _ ___2rLot size _._-__:�-'---," Water Supply: Public system ❑ Community system ❑ Private �epth to Water Table 7 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 Ej----New Construction: Yes ❑ No DiFHA/VA: Yes ❑ No [] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool p�rmitted if public sewer is available within 200 fee+.) 71 Septic a� nk: Dista ce from n#aresf well------------ --Distance from foundation___________ s�`Q --------.Material ❑ No. of compartrrients--------------------- ----Size--- Liquid depth Capacity ------------ Disposal Field: Distance from nearest well_...177�'/._,Distance from foundation--------------------Distance to nearest lot line-"_._______.____ i Number of lines--------------?------------------Length of each line_3_ _�_ � r` �Width of french__ _V/-- -_ Type of filter material--- ?-41_ Depth of filter material-___ s !' [ Total length --- ------------------- See ,� Distance to nearest welLCrzng_-maDteraaf e__from _ oize nDiameter_ D'stanc� DEnearest lot line�__._t"--�.- p 9 Dumber of ifs--__ . ; y = --,/ I De th " .a d �. . / ' p - ---- Lining. materia'-- Cesspool., Distance from.nearest well__-__--"-_-._-.-_Distance from foundation.__ ____,_. .{� ------------------------- ❑ Size. Diameter----;. ._____ __Liquid Capacity-.-._------------------- g D als. Privy: Distance from nearest well___-----_----------------------------------- ----Distance from nearest building__ ! ❑ Distance to nearest lot line___________----------------- Remodeling and/or repairing describe :----------197-C, ----: -- ,- � - -----•-.------�----- --- ----------- I ------------------ / -------------------- { ------------- ----------------------------------------- ------------------------------------------------------------------------------- I hereby certify t I have prepared this application and that the work will be dobe in accordance with San Joaquin County ordinances, State and rules an �1.7� mations of the San Joaquin Local Health District. [S, 'gned}- ------------/ (Owner and/or Contractor) By---------------------------------------- Title (Plot plan, showing size of lot, location -f s---- - --- stem in relation to wells, buildings, etc., can be placed on reverse side). ! FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- ' REVIEWED BY. ---------------- ------�----� �--------�------��-�- � DATE------ - -- --- --'�-�-�------r--� ------------------------------------------------- --------------- DATE------- -- --- -- - BUILDING PERMIT ISSUED - -------------- --- -- ------------- ------------------ DATE---------- - Alterations and/or recommen dgtion�:' 7b ri-4 -" . -� ----------- - � t : - ->.- FINAL INSPECTION BY:_..----� +- � G�'�-~�:. Date---.-.--.7 /-_ .- { SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelion Ave. 300 West Oak Street 124 Sycamore Street 205 Wes!9th Street Stockton,California Lodi,California Manteca,California Tracy, California F.P.0 O.