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FOR OFFICE�USE: --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ------------------__--_.--.,. _._. - --------- _(Complete in Duplicate) ------------------------------------------- -- 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 t e wor herein described. This application is made in compliancewithCounty Ordinance No 549. JOB ADDRESS i ATION-- { " L . /'� c - ---/--°------ ---- --_-•---•--`---------- i Owners Name_ -- -- ► -------------- ------------ - ---=------------ Phone-_Sd-----��`6f� Address ��_ �.��} '_L� � +I _(J .y -------- -- - Contractor's Name__ �3:A.�_ ._ - -�- ,�-,�r----- --- -- Phone.:T(P�a � k Installation will serve:. Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: j--- Number of bedroomsmber of baths 1 F 'L of size J. ----id-'-�---------------- e r Water Supply: Public system ❑. Community system Private ❑ Depth to ater Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ jay ❑°~Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date------------_._ ) ❑ ❑ / ❑ ❑ _____ No New Construction: Yes No FHA VA: Yes No TYPE OF INSTALLATION AND SPECIFICATIONS: iNo-septic Tank-dr-cesspool-perm itted�',if-�publ;c-= ewe; is-available=within-200 feet.)-'.~_. Septic Tank: Distance from nearest"well _______:__Distance fro undation-_- ©__ __ Mafierial__ ,fes �.� - -- .« �'1 + �� No, of compartments_. ____________ S, /it . Disposal Field: Distance from nearest well______________Distance from foundation---/.&-"- ¢ p ._1_.Distance to nearest lot line_____ Number,of lines_j___,��_________________-Length of-"each line_ _--�____ } � - � � �,�" �_�_.-_.Width of trench___�� Type,of.filter material- Depth',.of filter-material.___ __� ____Total length__________________/-( ____-____-__ r' .....r. i Seepage Pit: -`Distamce to nearest.well-________________ ____Distance from foundation__________A--------Distance to nearest lot line-.._.-----___..._ J ❑ Ni;4er 'of pits___ '--------------Lining ma#erial-----------------------Size: Diameter_________ i Depth `"------------------------- 7' Cesspool: Distance from nearest wellce:�DistanfromYfoundation___._____.____.--- Lining material--------------------------------------- 0" ___... ____ ______ ______._. Siie:$Diameter----I. £__ . __- -Depth------------------------------------------- .....Liquid Capacity---------------------------.gals. Privy: Distance„from nearest well-------------------------------------------------- from nearest ❑ Distain�ce_to"¢z ' ----------------------------------------------- -------------- building---------------------_------------------. nea`tst loline--------------------------- ---- - -- --- ----------- ------- -- Remodeling arid/or .repairing [describe]:'----------- --------- ----- ---------- ---------- ---- ' a _.. f li -"--------�1' ------ - ----------------------------------- -----------------------------------------• .... S. ------------ -------------- ---------- -- ---------- •-------------------------------- -- - ------------ - --------- § -- --r -` ------- -- - �-------------------------------------- --- - , {;hereby certify:+ha+-I•-have~prepared this application and'that #heti orktwill be,don in accordance with San Joaquin County { ordinances, ate laws and rules and -egul 'ons of the Sa Joaquih al_Health Dis+ c+. Si ned _ _ _ 9 /{��t{��/f �_ --------- '-- -- - - -----, r7andYo r Contractor] -:---------------------`-___----------------------------- - - -•----- ----- - Ti+le-------- --- -- (Plot pian, showing size of lot, location of system in relation wells, buildings, c.,,can be placed on reverse side). FOR DEPARTMENT USE ONLY ----- -------- REVIEWED -- / APPLICATION ACCEPTED BY f �ti' Or - ------------------------------ DATE --- `l_3...__: . !! REVIEWEDBY----------------------- --------r.........t--'------------ -----------------:- =--------:----------------------------- DATE---•------------------------- -------------- BUILDING PERMIT ISSUED--------------- j --------------------------------------- ---------------------------------- DATE------------- ( Alterations and/or recommendations - -------------------------------------------------------------------------------------- ---_----- ------ ---------------------------------------------------------- •--- ------------------- ------------------------------- -- - -- -------- ------ -- --- -- ----------------- -------------- ----- - ----- FINAL INSPECTIO • ._ .. . .. . ---- - Date ------------------------- � - y r . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E:Haxellon Ave:" 300 West Oak Street y` 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8.59. 3M 3-'63 F.P.CC.