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j FOP; OFFICE USE- APPLICATION------------ -------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No, r� _:r ---------------------------------------- --------------- (Complete in Duplicate) --------------------------------------------------- - - This Permit Expires 1 Year From Date Issued Date Issued _,.2__ 52_____. Application is hereby made to the San Joaquin Local Health District for a permit to nstruct and ins�aT he worn ere nrdescrbed. Thisapplication is made in compliance with County`Ordinance No. 549. Cn'✓ SUIV � 0/1-10'r1/70 --r, OB I)DRESS AND LOCATION--- __/-------- 0 ---------- ,---- -__-- �,y� Owner's Name----,W- -------vl,O41CS-•---- C71---------------------------------------------------- Phone- -------- --------- Address--------------------------------CIX09M 40--------------------------------------------- ------------------------------------------------------------------ - ---•-----.....__...--------------- Contrac.tor's Name----C—C—&7/,e:�.7/�✓�----... --------- ------------------------------------------- Phone_._ Installation will serve: Residence Apartment Hose ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J__-- Number of bedrooms __ ___ Number of baths J---- Lot size ------- `________________ Water 'Supply: Public system ❑ Community system ❑ PrivateX Depth to Water Table __60 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe/d, dobe Hardpan ❑ Previous Application Made: (If yes,date--------- ----------I No x New Construction. Yes ❑ No M FHA/VA: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well________________Distance from foundation-------------------Material--.---------,_------------------------------------ 'J ❑ No. of compartments----- -•- --- ---- -----Size--------------------------------Liquid depth--------------------------Capacity------------------ .. 0 Disposai Field: Distance from nearest well---60__----Distance from foundation:_ O_____.__.Distance to nearest lot line-- Number of lines___________ -------------- Length of each line_____ ------------- Width of french.---------- ADDlength Type of filter material$-��__Depth of filter materialo_Y_�_.._Total length________ _____________ 0-________- Seepage Pit: Distance to nearest ---Distance from foundation----1d; Distance to nearest lot line...... Gq(1S1141 Number of pits------- ...........Lining material__ . Size: Diamete:_, 6-�� ._Depth--------------- �5 __--.- Cesspool: Distance from nearest well-----------------Distance from foundation-----------------..,Lining material--------------------------- ----__._. ❑ Size: Diameter --- --------------- ----------------Depth---------------------------•------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well----------------------------------------.----------Distance from nearest building____._________________________.._______._. ❑ Distance to nearest lot line. ---------- ---------t ------------------------------------------------------'--------------------------------------- :, r Remodeling and/or repairing {describe):-- ----y � ------- 0------- --------•------•-•--- - ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ - ------ ------------------------- ------ -------- - - ------------ - ------------ --------------------------------------- -- -------- ----------- ------------------------------------- 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 San Joaquin Local Health District. (Signed)--------------� --/ A�_--C-J-C� �t� �1-�----------------------------------------------------- -----{Owner and/or Contractor) S By:----------------- - � - - - --- ------- ..—�..- - - ---------•--- ------ --- -----(Title)------------------------ ---_------------- ...... (Plot ------ - --------- - (Plot plan, showing size of lot, location of system ' relation to wells, buildings, etc., can be placed on rever'.se side). "..._ t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY............ � -------- - ----- -------------- --------------------------------- DATE----- 6 �� '` REVIEWEDBY------------------------------------ ------ -- ---------- -------------------------------------------------------.. DATE----- -- -- ------------------------------------------------ BUILDING PERMIT ISSUED-------------------------------- --------------------------- ------------- ----------- ---r- DATE---------------------------------------- Alterations and/or recommendations:____.. l - =r '' `-,�t-----k __ _ ----------- ---------------- - ___ _-__ ------------- --- . ^ --------------------- -----•------------- ------•----------- ---------------------------------------------------------- --------------------------- ...... ------ ----------------=---- ------------------------------------------- 1 i FINAL: INSPECTION BY:..---- ...-G-.- - --- - --------- - .Date----------------------.7 '� f ----- k SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CG.