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FOP OFFICE USE: T.�.�1............. APPLICATION FOR SANITY N PERMIT Permit No. :..1......... . Com lete in Du II l" ... ....... .......�..... ..........q..r.... ........ ( p P vI Date Issued ......:................ y.• ,-�j_�...; J..... . '. :_.1 ..c'. . This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct `dinstgl!the work herei��`erbe�. This b lication i'jmade in com ';ancce•twith /County Ordinance No. 54?/. :.'!a /,t C. st _ PP ; J/Ly,�" T 7� 6C. C%crt.1-1.- ............ JOB ADDRESS AND LOCATIO .,. �.�:�i..Gs......./�. ,................5.. ?.,.......-...-.t//c<<✓'..-�_ �- ....._...__......... i Owners Name....� - L..�•- ......... r-..44:4 . .2........ms..s...,... .....................................-.f.�............,.r...............P..h.one..:T��y........S.....s.....T i..b.. Address............ /. . ........................... ......................../. Contractor's Name........ ... �,,_/ ,4 .. ....................... Phone .. -....b �-...... Installation will serve: Residence ❑ Apartment House 0 Commercial R.l Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ........ Number of bedrooms ........ Number of baths .3.. Lot size ....... .......I........-.. Wafer Supply: Public system ❑ Community system ❑ Private ff Depth to Water Table .& ft. Character of soil to a depth of 3 feet: Sand❑ Gravel ❑ Sandy Loam❑ Clay Loam❑ Clay❑ Adobe,(f Hardpan❑ Previous Application Made: (if yes,date.... ...............) No g New Construction: YesX No ❑ FHA/VA:Yes❑ No/( TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) _ y C' } Septic Tank: Distance fromrnearest well.:.I...:.......Distance from foundatior4.... - P P ty2_<4gn��- Wo: of compa�.t"Jents........�..............Size.:'2.��....)(.3......Li uid de th.....`1k. Ca aci Disposal Field: Distance from nearest well.._S.G'. -...Distance from foundation...,3�G.........Distance to nearest lot ........ Number of line...........? ................Length of each line.........7-1" ......Width of trench....-......>O-e-- Type of filter material........ ...Depth of filter material...../ty.......Total length........................................ Seep ?e Pit: Distance to nearest wel!...le<.........Distance from foundation....`?-�.••--•Distance to nearest lot line............... Number of pits..:... ?.........Lining meieriai5-.�DC% ..Size: Diameter Depth.........''�s..�.-....... Cesspool: Distance from nearest well.................Distance from foundation................---Linurid Capacityterial-.......--••---•-•-- -••.-•-gals. ❑ Distance from nearest well.................Depth..................Distance from -.... q ............................ Privy: nearest building.................................... . . ................ ........... ......•-•--......................................................................... ❑ Distance to nearest lot line._...... ....... ..... Remodelir;g and/or repairing (d scribe):......_..- ............... •..................................... ... . _.... ..... ..............................•..........-----...........................----....--•--..-_......----.......-...._._.:............................................................ .._ I 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 rules and regulations of the San Joaquin Local Health District. , .........................(Signed)................. _' �..( nerand/or Contractor) ) ti�� ...................(Tifle).........f !By:................... (Plot plan, showing size of lot, locationof s em in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ .1 /':. _/ —_ . DATE......1...........��.lr. DATE....... ........................................ .. REVIEWED B ...................................... ._ ......... _................................................-......- DA , ✓ BUILDING PERMIT ISSUED............................i..............................-_............._.....,.......... . DATE... __,...._...................... IV. _ ....._--_-�-:.-.-.........f.c..,....�. Alterations and/or recommendations:........._ .._.. ._-,..L.. ...............`/..........t. -...;..-:...... %� -. .... .< -�-�....... .......:................ ..... ...- Dote.. FINAL INSPECTION BY:....... ..•._ _..._...... ......... ..... . __. -...... SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haaelten Ave. 300 Weil Oak Sher 124 Sycamore Street 203 Wal 9th sneer Stockton,Coii!orn{a Lodi,California Manteca,California Tracy,California CS 9 aeViSCD 8 59 ]M ]•'6] r.P.ClI.