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f rFOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. .11,5- ---- ----- -- ----------- --- --- ---------- --- (Complete in Duplicate) } - ------------------------------------ ___________________ This Permit Expires 1 Year From Date Issued Date issued (9 q(-400-0 7 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the wo erein scribep. This application is.made in compliance with County Ordinance No. 549. It're � x f jQ s� t41, le. 7 / Al. 'Tu LJOB ADDRESS AND C/A�TIO Nyy - k Owner's Name ��G ------------------ Address �r Iry �f Phone h_one Address--------- ---------- -------- Lfl/- Contractor's Name--------------- ------------------------------- ----------------------------------------------- Phone--------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial E]/Trailer Gori- [Motel ❑ Other ❑ Number of living units: _1___ Number of bedrooms a2_ Number of baths /___ Lot size -__Lc�Lf1�� 11 _"-------------------------- Water Supply: Public system ❑ Community system ❑ Private [Depth to Water Table d9 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--------. ----------) No I' New Construction: Yes �No ❑ FHA/VA: Yes ❑ No [�qr" TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 011 f f Septic Twk: Distance from nearest w�IL � ..__Distancefrom foundation__,lr�__ ____.__.Mater,,I _e- E` _ _ ------------ No. __________ �� No. of compartments__ _,-(-,-------------------Size- -- ---- - Q-----Liquid depth----��-'___------Capacity-��-s--f.�-------- Disposal Field: Distance from nearest well.//-W----- from foundation_!______._-_Distance to nearest lob line-949- ......... Number of lines----- Length of each line-- __ �__.Wi th of trench-_a. --__ 9 '- d �...---- T e of filter materialf _ De th of filfer material____ __ Total len th__ fl___________ Type �' p g f /'�j ��v Seepage it: Distance to nearest well____ ______Distance fr foundafion__/ -_____.__.DiSf nce to nearest t lin [ Number of pits_______...__..__Lining material___ > _Size: Diameter_ �`-_-_--Depth_40- .-ff 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----------------- ---------------------------------------------------------------------------- --------- ------------------ ----------- Remodeling and/or repairing (describe):----:_.___ _-- _ 1 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 r es an4re of the San Joaquin Local Health District. (Signed)--------•------- ------f ---I—- -- ----------- ------ ---- --------------------------- -----------(O r Contractor) I. $Y:--------------------••-----------------•---------------------------------------- Fp`'_- -- � ---------------(Title)--- �a�/�r------- (Plot -- - ---- (Plot plan, showing size of lot, location of system in re"i rt we Is, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------- DATE J- ---- ------ ----- --------------- ----------------- REVIEWEDBY----------------------------------------- ------ -- --------------- --------------------------------------- DATE----- BUILDINGPERMIT ISSUED------------------------------------------------- ------------—------------------------ ......------ DATE-------:-------i---------------------------- --------------- Alterations and/or commendations _ _ _ ______ - rCj --� __- - L-- --------- _-- -- -------------------------------y ------------ --------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:. DateIX-- 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 P.F-.r o.