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FOROFFI E 5E: 1� ` �l - �a./-- - � ' PPLICATiON FOR SANITATION PERMIT Permit No. ---`--------------- -- -------- ------------ -------- (Complete in Duplicate) Date issupd�._..��jb This Permit Expires 1 Year From Date Issued r> �, Application is hereby made to the San-Joaquin Local Health D' trict for a permit to construct and install the work herein described.This application is made in compliance with County Ordinan No. 549. JOB ADDRESS ANp LOCATION �--•__ _______ _____ _ l� _. T ----- Owner's Name_ r1_.�s2 _ 1LL. -----.�_ -fi. —--------------- -•- p-ar 1 -------•- - ---•------ -- Phone_--- -•-••------ -•--------•--------------------- Address_...� 1� ,c.�� f. t = .f1 /.. Contractor's Name,--- --------- Installation -------Installation will serve: Residence Ejpartmenf House Commercial ❑ Trailer Motel ❑ Other ❑ �. Number of living units: _ � N er of bedroomsNumber of baths I___ Lot size __. r Water Supply: Public system Community system ❑ Private ❑ Depth ro Water Table _loft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ dobe ff<ardpan ❑ Previous Application Made: (If yes,date__ ______________) No ❑ New Construction: Yes ❑ No FHA/VA: Yes ❑ No ❑ i TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank-or-cesspe l permitted if-public seweF is avail ble within 200 feet.) Septi Tank: Distance fro'm nearest w 11-�07�Distance fro f io 1l a f -...Material---- ..---- -- No..of.coni artments.____ -----------------Size _ Liquid de th_-, -----=-�-.- Ca aci � r P r/ q P. P tY I Disposal Field: Distance from near st well- �.�k-�Distance from foundation-, _:-_ f � � r f�_.-------- _..___Distance to lnearest lot line__ Number of lines-- _____ --,__Length of each line-L, _____/------ __.Width of trench___-- - _'�-- Seepa e Pit: Distance to nearest.wel!__�_�.._0_`_)C!_-h-=-__Distance--f';'�lter material--�,j° .c��( Total length_.,�,�,�'f',.,____�__•_Y._� Type of filter material.. .___ c__._. Depth of _ �n p s�-____Lining mate "--Size: Diam©r ---.Depth______. -, '� �f jlll„1 i Prein foundation-----=l'..__. __. Number of its___..____ ter--- rial_.. a r ` Distance to nearest lot line •-----_ P Lining material #---._...•---- .... f- ---------- Cesspool: SDizeeDa eter_near�t-.well_________________lpep+Ince from foundation__._---- .Liquid Ca aci �-- ` �• P ,ty- ---------.-gals, Privy: Distance from nearest-well,_..____- �..-----...7.._-'Distance from nearest bwldin -a--______- - 9= �_ ID Distance to nearest lot line----_...__________,--`------ - - - #"_ ----------------- ----------------- ---- - -- ----------- ------ UPSTAIRS NOT TO-QBE USED F BT TATION r1 S.3:`L.H.D. Remodeling an or repairing escn a :____:_ - ' -... -- ----- - R"'� ------------------------------------ hereby certify that I hav prepared this applicat' d tha�the wont will be,done in accorditice with San Joaquin C I. ounty ordinances, State la s, and rules and regulations of th San Joa u n-'Local Health District. (Signed)---- -----e• �F-- -�F9- - =� _1_Cs_'u- � lr1f l sL2 -------------- C9nt1ractorJ By:-----------••----- --_-----------•---------------- - (Title)le)--------------------------------------- ------------------- (Plot plan, showing size of-lot;-location of cyst in rel5tion to wells,b dings, etc:,- an'be placed on reverse sid"e). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- ---------------------------------- ............ �_ )--- --- DATE----------,--'-r��- ! � REVIEWEDBY •------------------•-----------------.------- -----.-----•------ -------•------- DATE------------•-- f IN PERMIT ISSUED ---------------------------------------.. ------------------- DATE. Alterations and/or recommendations•__ti Z-}3 - (o: s1^ --- ------i _ .t►1 _ _----------- . ....... }` ------------ w Z.. ' _.00.k---------------------------t --- Y ---------------------- -------------------- -----------------------•-------------------••---- ------------------•-------------------- ----•-------------------- ---------------- --- I ,7 FINAL INSPECTION BY: -__ _ Date__.__ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 114 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California 1cp� ES 9 REVISED 8.59 2M 5-62 ATLAS -�-;,� �,r