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FOR OFFICE USE: , ---------------------------------------- --------------------------------------- - APPLICATION FOR SANITATION PERMIT Permit No. '22---1,�.7p --------------- -- --------------- -------------------- - (Complete plicate) ---------------------------- ---------------------------- This Permit I:xptrese] YeauFrtsrrt Date Issued Date Issued _ .. I 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 LO TIO .____.-_C�'3__1-S.7a------tr_,Q. .vx.�,t,---------- .. Owner's Name------------- -- ---- --- • ------- --------------------------------------------- Phone------------------------------ Address-------------- 45-4,.X--•---------- .-�2�t '- - ,p < - --------------•---•----- Contractor's Name--------.__�e--•--� _. ----------•----- --------C.-: .. : Phone�!_.li� P-1 Installation will serve: Residence �L Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/_-- Number of bedrooms -,, -__ Number of baths .,2___ Lot size .._l Q__ _./t _______________ Water Supply: Public systetm ❑ Community system ❑ Private X Depth To Water Table raft. Character of soil to a depth'of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe, ' Hardpan ❑ Previous Application Made:'(If yes,date-------------------.) NON New Constru0ion: Yes ❑ No V FHA/VA: Yes ❑ No& 1 4 TYPE OF INSTALLATION AND SPECIFICATIONS: s (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank:, , Distance from nearest well_________________Distance from foundation------------------..Material......__.--____.._..._______.......__.__________- ❑ PX/f7_id4o. of compartments ----f--Size--------- Liquid depth Capacity._.. Disposal Field: Distance from nearest well.____:__- ___ _Distance from foundation__ 10 Distance to nearest lot line•_____.._. ❑jVd Number of lines__________________________________Length of each line_________._.--_D___.......__.Width of trench.____._. ------------------ Z71- ri-4'6 Type offilter material._._.__ z _Depth of filter material-------Id_L._.__Total length......... ..................... .A Seep it:. ... Distance to nearest elle__ .__ __ istance fa ndati a_.__ rete to Barest of Ii c �•. Number'ofYpits ---- - ----Li g m e ae: er- D Cesspool: Distance,fiom'nearest well_________________ Distance from foundation___________ _ Lining material------------------------------------- C% ❑ Size: Diameter--------------------------------------Depth----•-----------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well ___-__-_---____________________________-----Distance from nearest building__- _--___-__--__--_-----------________. .❑ Distance tb nearest lot line: ------•--------•-•------------•-•-------------- Remodeling and/or repairing {describe:____ --- - -_--- 10 ---------------------- k ------------------------------------ ------ I hereby certify that l haus prepared chi 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. Owner and/or Contractor (Signed) - ----------------------- ( / ) BY= � Title - (Title) (Piot plan, showing size of I , Iocation f system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- ----------- DATE-------------- - --1��----------------- --- ! ------- -------- ----- ---- -- REVIEWEDBY-------------------------------------------- ----------------------------------•-- ---------------------------- DATE------------------------------------ -------------------- BUILDINGPERMITISSUED------------------------------------------------------------...---------------------------------------- DATE------------------------------------------------------------ Alterationsand/or recommendations:--------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------- ................._....._..._..-------------•--------•----------------- --------------- -----------------------------------•--------------•---------•---------------•--------------------- ................................. -------------------------------------------•------------------------------------- -----------------------.--------------------------—-------• ------------------..--. --. -- FINAL INSPECTION BY. ------- , l �7 -0------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California pp ES 9 REVISED 9.59 ZM 5-6Z ATLAS = .