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FOR OFFICE USE: --�------ - - ----�Vv----------------------- APPLICATION FOR SANITATION PERMIT Permit No. ....1-�.�--�• f ------------ - -- --------- --- --------- ----------- (Complete in Duplicate) Date Issued --_3�y� --------------_-----__----------__.._.__--_ -- This permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Healfh District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. F --------------------------------------------------------------- _-----------ADDRESS AND OCATION 0--��- r`�- -- �C -------- Phone------------------------------------ Owner's Name �1/jlL� ! � •••--•------------------•----------------------I--•------------------- Address ?� - ---------------- • � - �------• " ••• - Contractor's Name--------••_`_=�rif 10111 - .� --------------------------•---•---- Phone......... ------ Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __!___ Number of bedrooms ___f__ Number of baths _�..-_ Lot size . --f. -. •--•---••------------------ Water Supply: Public system 0-1,C-ommunity system ❑ Private ❑ Depth to Water Table 6,01�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--------------------I No [ New Construction: Yes ❑ No O-'_F_HA/VA: Yes ❑ No 95—" TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se tic Tank- ' Distance from nearest well_________________Distance from foundation-------------------Material-------------------------------------------------- `yr� / No. of compartments--------------------------Size----------------__------------Liquid depth-------------------------,Capacity----------------------- Disposal --------------------- pP Distance from foundation--- --I-..Distance to nearest lot line___ ' Di�� Field: Distance from nearest well ____ Length of each line------ �-� f� Width of trench.____ _�____________________ Number of lines_- _______ � - er material. _ _ '( 1✓Depth of filter material____/�______-_._Total length___.__, ____---------------------- Type of ft # Distance from fo ndation__..A�./----.Dist Distance to nearest Trot line----------- P01— p g nearest�well_.____:��_ Seepage Number of pits-------.1------------Lining material X14' __.Size: Diameter-- - ' _:___:_: --- ----------------- \ ;. Cesspool: Distance from nearest well-----------------Distance from foundation----------------_---Lining-material-__.____.____-.____._-.____________--. b � ❑ Size: Diameter----------------------------- --------Depth---------------------------------------------- :Liquid Capacity----------------------------gals. Privy: Distance from nearest well-______________________-_.__.--�_.________.___-Distance from nearest building------------------------------__.._____- 1 ❑ Distance to nearest [of line-------------------------------- -- ------- --------------- -_.:..------------------------------------------------------------- Remodeling and/or repairing (clescril e)------------------ r ;i--r--------- -------------------------------------------------------- ------------------- 1 ------------------------------------------------------------------- ----------------------------•----------------- __-_______.____--._____-____________________________1___ _______________-___.....________.___-__________-__-._____-_-_-________..-_________-_______ -____--------------------------------------------------.----------------- 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 and regulations of the an Joaquin Local Health District. (Signed) -� r� - -- --- ----- ----�� ------------------------------------ r Contractor] . �"�f]. [� A X. - - - --- - - ----------- -------- (Plot plan, showing size of lot,'location of system in rela ' 0 wel s, buildings, etc., can be placed on reverse side). i k FOR DEPARTMENT USE ONLY r / APPLICATION ACCEPTED BY- e l�� r-sds�F -------------------------------------------- DATE '�`� l REVIEWEDBY-------- ------------------ --------------- • DATE...... ------------------..---------•--•-------------------- BUILDINGPERMIT ISSUED---"---------- -- ------------------- • •----------------------- DATE-------------------------------- -------•-------------------- d Alterations and/or recommendations_____________._..__._ .. Y t - --•------- -------------------------------- ----__--•----------_ ---- ------ ---- 3 ------------------------------------------_------------------ ---------- ----------•------------------------------------------------------------------------------- FINAL INSPECTION BY: �y------- I -fit C - Date_ " -.1-. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street y z x'124 Sycamore screel 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California 6•fi0 ES-9 REVISED B•69 F.P.00.2M v ,.r