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FC) OF�I -- USE: - ------------------------------------------ APPLICATION FOR SANITATION PERMIT Permit No. ..[..-7.�: ----------------- T- -. (Complete in Duplicate) �i r bate Issued --- ____----____-------_----_-------___-----____._____ ___ '-This Permit Expires 1 Year From Date Issued 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 LOCATION- --�_- ---1-2. ...---:5-- ---Y1-4y------�-------------------•-------------------------------------------------------------------- Owner's Name--___ -,r- , - - Phone --------- Address----------` 4-Yi -----------7- 1------•-----•-------------•------� - --------------- -- --.... Contractor's Name-------- L ---------------------------------- ------ Phone-------•--------------... ------------------------------------------------------------ --- - Installation will serve: Residence [] Apartment House ❑ Commercial ❑ Trailer Court [, Motel ❑ Other ❑ �l Number of living units- -.-,'Number of bedrooms -------- Number of baths --------- Lot size ----- --_'Z_--- R._ -------------- Water - _---.---_Water Supply: Public-system ❑ Community system ❑ Private M Depth ha.Wate able #.t:, Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe R) Hardpan ❑ Previous Application Made: (If yes,date---------------------) No & New Construction: Yes No ❑ PHA/VA: Yes ❑ No ti ' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I - Septic Tank: Distance from nearest well-_-7-0-------Distance from foundation__h-O-b4?�_MateriaL [� - - _ deh .._ -------No:ofcomprtens---=-- - CaP ctty= --QO Q • . k Disposal Field: Distance from nearest well__.SS--_-Distance from foundation_-X-Q--sk-.--Distance to nearest lot line---------------- . Number of line._.2-----��:--_-------I_ .-.-_Length of each line---------4.0---i----.---.Width of trench - -EI---------------- "' Type of filterYmaerial.5?,.rU4- --Dbptl-of filter mater.ial_---_�-�-_-_-__._Total length--_-_----- ----------- wW Seepage Pit: Distance to nearest well'---------- ------Distance from foundation----................Distance to nearest lot line_--------------- �J ❑ Number of pits'--------------------Lining material__-------------------Size: Diameter----.-----------------Depth---------.-------•--------- ---- 4' 1 P Size: Diamete---------------------------------e_II_ ---- :-Distance f rom foundation-:-----------------.Lining material_--.----------=--------------------•-� n Cess❑ool: Distance.from r--aresell_"�-7n7: 15�pt�h-----------------------------------------------------_ Liquid Capacity----------- -------------gals. �/ Privy: Distance.from.nearest well____ t --- -----------Distance from nearest building------------- ------ ---- --------- ❑ Distance to nearest lotline '} .' -Y -------- ---------. n Y ;------- , -- D-Q-Sj__) r s Remodeling and/or repairin (describe):_=��`-V _ _. . —----- - K_-C, } _ — ]Qrlf 14 L _1 r (� - - A-Him------a: --__-. ------l61_ .____ __-�►1- 1_______-------------------------------- _______________________ Ihereby certtfythat I have pry pad his application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules�arid regulations of-.the San Joaquin Local Health District. , t (Signed)---------------------- ---------------------- ------------------ --------------------------------------- ----------------------{Owner and/or Contractor] r /Xhiowing -----.- �._' , -----(Title)-------------------------------------------�-------------------c'(Plot plan size of_lot, locatio of-sysfem::in reiationTtowells,-Ibuildings, etc., can be placed on reverse side). 3 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED -- -`-------- DATE----to-- 4' - ------ .. ., -. , REVIEWEDBY-----------------------------T-------------- -------------------------------- ---- -- = � = -- - -----------------------._ DATE------------------------------------ BUILDING ---------------------------------BUILDING PERMIT ISSUED--=-------------------------------------------?---------------=-="-------- ------------------------- DATE------ ------------------------------- -- ------------------- Alterations and/or recommendations:-------------------------------------------- -------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------- ----------------------------- ----------------------------------------•------------------------------------ -------------------------------------•----------------------------------•------•----------------------------------------------------- -------------------------------------------------------•--------------------- --------------•------------------------------------------------------------------------------•--------------------------•--•------------------- ------------------ •----- ------------ -.-. -- ------------------------------------------------------------------- FINAL - ----FINAL INSPECTION BY:._ Date k_() -' - ----------- -------- ' } SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street r Stockton,California Lodi,California Manteca,California Tracy,California s 99 9 REVISED 6.59 3M 3-'63 F.P.CD. - f