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FOR OFFICE USE: 5 � �� • � -- ------ 1 "" " """"" , I�l�_-_ APPLICATION FOR SANITATION PERMIT Permit No. ____-f.7._._�Z3Q ----- -- --------------------- {Complete-in Duplicate) /r -+ _. _ . Date Issued This Permit Expires 1 Year From Date Issued Application is hereby made tolthe San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliant ith County Ordinance No. 549. Ir JOB ADDRESS AND LOCA' ION..-----"""_-- -- --- --� r' - --- -�------------- (------------- /I - ---- ------- - ----- -- -- -------------------------- -- --------- --- It e-n -.L Phone Owner's Name--''`�=-•--------- ----------------- -- -- -- - - --------------- Address............. -''e !"�'�;c--. 1.1--?'..h./ ---------------------------------------------------------------------- ._----------------- Contractor's Name C.r fi�I~ �� ---------------- ---------- ------------------------ -_-------------•-------. _ Phone.---..-.-----------------"--•-----_ Installation will serve;;Residence, partment House ❑ Commercial [] *Trai er Court ❑ Motel ❑ Other ❑ Number of living units:�_�--" Number of bedrooms _ Number of baths!=_____._ Lot size "--___ Q�._.X..l__ _ ______________ E _. Water Supply: Public€system E]. Community system [I Private �epth to Water Table_.__ ft. Character of soil to a depth of-3 feet:Sand []'"Gravel"❑'""Sandy Lo am 4- ❑'-'"Clay,1 oam'❑"Clay'❑Adobe EreFardpan ❑ ` Previous Application Made: (If yes,date..------------------I No V New Construction: Yes Pe"Neo ❑ FHA/VA: Yes ❑ No Lk, TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspoo I„p�rmiffedjf public sewer is available within 200 feet.), - t Septic Tank: Distance from nearest we1j__ Q_______D' t1 �eVfrorr� flgund�tion. .-__-..___t.Matgrl 1."_- .. __- "..".-_ ." """"""_"__.._________. o. of compartments--___ _.".._____-_...Size�'t�___ Ij'�r _--Liquid de th------------------------Capacity -.�- Disposal Field: Distance from nearest—well._ G/ ..._Distance from•foundation.. 1 Q__�___.Distance to nearest Iot I' e . Nu'mber of lines_______ ___ __________�_ } Length of each line------------- Width of trench--- Type,of.filter. of.filter material---------1_ _____Total length________________p�� Q. ._ 1 Seepage Pit: r� Distance to nearest well___'---- 3-----D.iStance from foundation-------------------.Distance to nearest lot'line----------------- � - ❑ .` Np fiber.-,ofspits------------------!--L n ni g_mate'rial---------------v-�` Size:._D_iameter_---------------_------Depth---------!----------------------- i i� k-`-s Cesspool: Distance from nearest well__ ____________Distance from foundation_____._.__..______..Lining material-------------------------------------- ❑ �i�e: Diameter-- --i�� } ----- Depth ------ -------------------------- --------Liquid Capacity---- - ----------- 7 --------- gals. r' Distance from, building Priv Distance from nearest well t _____..____- ❑ Distance to nearest lo'f%line___________________ I -- ---------------------- -- --- ---------------------------------------------------- Remodeling and/or lrepairing (describe}: --------- --------------- ---------------------------------"-----------------------I-------------------------------- --------- -----.-- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --- ---------------)------------------- ----------------------------------------------------------------------------------------------------------------------------- i ------ --------- {: I ; s, 1 hereby certify'that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances State law5, ules and regulations of the San Joaquin Local :Health District. (Signed)- `: �"---:---- ±--' -,-- - --- -- ------ ---------- ---- L----------- ----- --- -------------------------------------(Owner and/or Contractor) . is } By: _ f = - ------- - {Title}- (Plot plan, showing.slze of lotllocation of system in relation to wells,.buildings, etc., can be placed on reverse side). f E i FOR DEPARTMENT USE-ON Y APPLICATION' ACCEPTED BY--------------------------------------------------------------- DATE------ -- -- -- ---- lt REVIEWED BYJ------1- ' = --- --.-------- --------------- DATE•---------------- - ---- = BUILDING PERMIT ISSUED--------:-----------------=----------------------------------—---------------------------- --------- DATE--------------------------- ---------- t Alterations and/,or recommendations:""-- -------Y:.-_-_-- _-- __-- - -- rt `+ - ---------,-4p!.." - -- _-"_.__- ________________________________________________________________________________________________-- __- ------------------------ ; ---------------------- ------------------------------------------- ---------------------- ------------------------------------- ---------------------- ----- - FINAL INSPECTION BY-------------- r' ` '------------- -------- Date-..------- ......----- 1 1 I SAN JOAQUIN LOCAL HEALTH DISTRICT i 1401 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California ' Lodi,California Manteca,California Tracy,California E5 9 REVM.KD B-59 3M 3-'63 F.P.CD.