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1 F R0 ICE USE: J` -� Ll SW '* ::�jf APPLICATION FORI'SANIT�ATION PERMIT Permit No. .. .... ..... .. ---- -- -- [,f ........------ • (Complete in Duplicate) -•---•-- Date Issued _.....--- ......... ------------ . This Permit Expires 1 Year From Date Issued ------- Application lslhereby 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 Or inance No. 549. JOB ADDRESS AN DLO T N._ _ `- S .---- ---------------•-- :_...__. Owner's Name. .X ,- := :::..,aT-:-- ___.;.rte-�° _ ................... Phone................. .................. - �/•- Address.......... 1 11 --.....- --- - ----••-----------•-------------------------------------------------------------------- Contractor's Name....................... --.----....•... f--------------------- Phone stallation will serve: Residence Apartment Nouse ❑ Commercial E] Trailer Court E] Motel ❑ Other E3t Number of living units: f---- Number of bedrooms�_. Number of baths Lot size _ .. '/ao------- ------ -- --------- Water Supply: Public system M Community system ❑ Pr ate.❑ Depth to Water,Table -------- Character 0Character ofsoil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam❑ Clay Loam ❑ Clay ❑ Aclolbe'§6 Hardpan [I Previous Application Made: (If yes,datef qS-7 -l...) No ❑ New Construction; Yes ❑ No;f FHA/VA: Yes ❑ No ❑ tTYPE OF INSTALLATION AND SPECIFICATIONS: ,+ (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �. s ' Tank: Distance from nearest well-.___�.__.....Distance from foundation...................Material..._..:....-.______...__.._.................._. No. of compartments---.............`"."•.....ze__`--�"`�`---�'~"--Liquid depth..._...--.--_�_--- - ..-Capacity....................... Disposal Field: Distance from nearest well/sQr+R_.Distance from 'foundation../-Q-.......Distance to nearest lot line-j-,,,...... F Number of lines------ _ p Length of each line_._. L?..____.,�_..._.Width,of trench-. .' ,........ .. . .... Type of filter,material,___s,. .Qr .._Depth of filter material_._ ----------Total length________ --------- Seepage -----_ 0-..•.._._ Pit: I Distance to nearest Distance f om fo ndaticn_ eQf._.___.Distance to nearest lot Iine�..S..... 1� z • 3 3. . ."De th t Numberi of its _..l_.__. ....___Lining mater al � Size: Diameter___._ -. p - ---- Cesspool: Distance from neardst,well____._-__.----'.;Distance from foundation_... ..............Liningsma#erial..................................... ❑ 4 . i••+► Size: Diameter............................ ....----Depth..............................- ---- - ----Liquid Icapacity............................gals. Privy: I Distance from nearest well—.............. ..............................Distance from nearest building........................._._..._.__...... ❑ Distance to nearest lot line ----•-----•-•--1-----•....................••• ..........------------- ------------------------- Remodeling and/or ...---------•.............:.........................•--••-••......--_... r •repairingP(describej:-=��-^�^s_^-�:TM��'-^--:.......,•••-•------------ � �-•"""'"-"-'-•-""'-'. � i f •--------- . ---------------- ---- ------------- A --------------••----••-•-•--------•-••--11 p---•----•--•-----••-•--•---------------•----.7----•-----. -.--_'------•- ' ' -IL i ' ---- -------------_---------___. ....__ .__-__--__..._-___....._._______--..._____-..------___._____--___._-__.__._'•__...__..._._,. __c______.___�____-o;_.._,__....-....-.....___._...... I hereby cert' that I have prepared this application and that the work<willle`done in accordance with San Joaquin County ordinances, St` I ws, anc{� rules and regulations of the San Joaquin Local Health District: Si ned l #�: --- ------------- - ---------- caner and/or Contractor] By:. - ---------- - --------'•------------------(Ti+le ... c ..._.. .. - (Plot plan, showing size of lot, location of system in relati wells, buildings, etc., can be place on reverse side). I ; FOR DEPARTMENT USE. ONLY APPLICATION ACCEPTED BY - -j-- ----- ....... DATE- _. k'r� �r, --�... . -- ---------------------- s DATE. •-----.----•---------•---------------------------•-••--- REVIEWED BY----- -------- -_------------------- - BUILDING PERMITiISSUED.._:+,s._„°'�.-.- 'y .. ... -••-•--•---........... . ........ - DATE.......... ....---�--_--•-•---•---_•---•---_----.---- Alterations and/or,recommendations:_._.-r' �� -- - ••••= 'r �� r ` -``cam''~"` '" A'`r` �"' i. .k, .... �G�?—�sL�� L, ................................................... ............. --- ...---•------- ---•--_-----•--........_....... Pi ........ .............................. tolL .................................. :..... ....................... ........... . .................................. .,..................... .... � 1 / r0AN �' Date_......-- - - � ' .............................. FINAL INSPECTION BY: L�.i ------- -----• / AQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 3ak Street 124 Sycamore Street 205 West 9th Street Stockton, California Lodi,California Manteca, California Tracy, California ES 9 REVISED 6-59 3M 3-'63 F.P.CD.