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1+ a� APPLICATION FOR SANITATION PERMIT Permit No. .__ t ._._ (Complete in Duplicate) Date issued ___tf___Z<e-: ' This Permit Expires-1 Year From 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 Ordinances No. 541?. JOB ADDRESS AND LOCATION- - --------� - ----------`/ Owner's Name------- --�---`l� Y.?�l ---- - Phone Address---------------- �- --Wit'------------ Phone----------------------------------- Contractor's `-c/- --------------------------------------------------------------------------------------------------- - Phone---•----------------••--------.---- Contractor's Name................ ! Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ----._ Number of bedrooms t __ Number of baths -_l_-- Lot size _.__��__.k_1_ /-------------------------- Water Supply: Public Jsystem ❑ Community system Private ❑ Depth to Water Table _&I ft. e Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 99"H rdpan ❑ Previous Applicafio Made: Yes ❑ No F_-New Construction: Yes p'No ❑ FHA/VA: Yes 9?--No ❑ j TYPE OF INSTALLATION AND SPECIFICATIONS: + J (No septic tank or cesspool permitted�f public sewer is available within 200 feet.) I r �p I Septic T k: Distance.from neatest well-».."-d^Distance-fror oundation____.` __.____..Material--_C.t__ - ---________ -------- Septic T,4,k: Disfancj�_Lroa neatesf-we4ta�^Dista nee ounclation------------------ e ac t No, of compartments......_s2'------- a---------Liqui d _ptj--- "_k--------------Capacity--� Size__^_ Disposal ield: Distance from nearest well-------.'------Distance from foundation----------------- Distance to nearest lot line--- _----_r4.. Number of lines--_------- -... ength of each line__--Aw-----.-_..:Width of trench-___..` _.�� _ ------------------ Type of filter material _ _. * epth of filter mate `�" ( Total length- �� p Seepage it: Distance to nearest well------ '------Distance from fpundation__------ -_--__..Distance to nearest lot line--c---- _ Number of pits-----�____-------Lining material ___ Size:-Diameter: Af_---_Depth--_�4 ----------_._...._ \ Cesspool: Distance from nearest well-----------------Distance from foundation---------------------Lining material-------------------------------------- S ize: -._-__---.._ -..-------.---_-----.--.Size: Diameter--------------------------------------Depth--------------------- -----------------------------Liquid Capacity----------•------------ gals. ` l Distance from nearest building �] I Privy: � Distance from nearest well--------- - -------------------- - ---- - g------ --------------------- ----------- .n lot line.------------------------------------------------------------------------s------------------------------------------------------------------- (: ------------------ Remodelingand/or repairing describe , is ante o nearest i ! = �------------ •------------------------------------------------------------ : -------------------.-------------------------------- 1 --------------- ------------- ------------------------------------------------------'------------------------------------------•------------ - --- I hereby cerfify,thaf I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S+ate laws, and rules and regulations of the San Joa uin Local Health District. (Signed)------.............. ` <� t n4 �� :q--- -- -- - ------- ----------------- � --- --------(�r Contractor] I By:------------------------------------------------- ---------- -------------------------------------------(Title)-- ✓ �'�'" . ...---------- --------- (Plot plan, showing size of lot, locati of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY p APPLICATION ACCEPTED BY-------`[-tR4O `-------------------------------------------------------------------- DATE----- l f�l ------------------------- REVIEWEDBY----------------------------------------------'s---------------------------------------------------------•-------------------- DATE------------------------------------------------------------- BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------- ------------ DATE------------------------------------------------------------- Alterations and/or recon mendations:-- - ----------- ------ --------•-•--------- ......_-------------------------------------------------------------------- - - -- 1-95 ---------------- ------------- ------ "- ,, l t - �._1(_. .-_ --------------------------------------------------------------.------------------------------------------------------------------------------------------------------------------------ --------•------------------------- ------------------------- ---------------------------(_----------------------------------------------------------------I-------------------------------------------------------------------------------------------------.- ------------------------- - ------ ------------- ---------------------- --------------------- ----------------------- ------ ----------------- ----------------------- FINALINSPECTION BY: ----•--- --------------------------- ---------- Dat v-------------------- ---------------------------------------------------- SAN JOAQUIN-LOCAL HEALTH DISTRICT 130 South American Street 300 West 0ak'Street� 132;Syc more%Street 814 North "C" Street- Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M Revised S-'59 F,P.Co.