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FOR OFFICE USE: 4-e I K9 - -------------------------- N �-- - Permit No. I Z- ----------------------- ------ APPLICATION FORNSANITATION PERMIT 7�( -------------- -------------------------- (Complete in Duplicate) Date issued --------------------------------- -------------------j ------- -i.-- This Permit Exoires. I Year From Date Issued --------------- ----lm�--------------------- 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 cb' liance with County Ordinance No. 549. ........................................................I------------------- JOB ADDRESS AND LOCATION-------- ---- -- -------- 40 .....-Z/--/ Phon .t------------ ------------------ ----- ---------- Owners Name---------------- -------------................... ................................... -------------------- -------------------------------- Address------ .........---- ------------------------ ---------------------------------- --------- --- I ....... Phone----------- --------------------- Contractor's -•-----=-------------------•- -- ❑ Other 0 Installation will sdrve.'-, Residence E] Apairtment House 0 Commercial railer Court 0 Motel El ----------------------- ... 4R 1 1 � --------------- Number of living unifs.�_Z;_:!�,Number of bedrooms-=?--- Number of baths __7ff.:'Lot size II ----- Water. Supply: Public systeI m El Community system 0 Private Depth TO Wafer Tabie .—,- ft. 4 1' I Clay Loam El Clay ❑ Adobe 3--oardpan ❑0 Character of soilfo a depth 3 feet: Send I Gravel 0 Sandy Loam 0 Previous Applicatidh'Mid (Ifyes-,cicite ...4_P.) IN o [D New Construction: Yes C] No B--1FHA/VA,. Yes ❑ No El �A TYPE OF INSTALLATION 1XND SPECIFICATIONS: k or cesspool sspool permitted if public sewer is available within 200 feet.) (No septic tan 0 4 11 _e ----------- i I efron�founclafion__./_�y-----MateriaL. ?,-Septic Tpnk, Distance from nearest well-_ Distanc 14-1 acity--------�jj—_o of Isom ---------_--------------- 2N- Size_ -IV C ---Liquid depth__......... 1 .......cap 011 11: ionA....... to nearest lot line_---. Disposal Field: Distance, from ares4�'w.ell ,zj7i I .n.6*,Distance 4rom foundat x It f I "t 0 Width of'trench----------------------------------- Ler�'Lth 0 each line----------------------------•-of lin ------------Length 1 mandation . -4 ------------- type of, filter material._._.--------- l316pth,of ifter� aterial I_---------_--Total length---- ------------ 'A tm It un 'ation....... --,Distance to nearest lot line-------_------- ----Di tance from fou ------ Seepage Pit: Distance to,ned.176st well------------------ is ----------------------------- .10 ...1--------Lining material..----•------------- Size: Diameter----------•----------"De--------_--------------Depth ,A\Number of pits---------- 0 -------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material'.-----------_.. -------------------------------------------------Liquid Capacity---------------------_----gals. Si -------------Depth Size:.Diameter-------------- ------- Prom nearest well_"_,-""-""------------------------------------ rest building----------------------------------------- Privy- Distance -Distance from nearest e to nearest lotline------------------------------------------------------------------•--------------------------------------------------------------------- "Cl Distant A. # ------------_------------ Remodeling and/or repai=9 scribe): . ........ 01 I .. .. - ---------- ------------------------ ---------- -------- - -------- --- ------------------------------il�. ------------------------ ---------- ------------ --- ----------- ------------------- .......... ----- ------------ ------------- ----- ----- ------------ ------- -7 ------------------------------------------------- -------------------------- -----------•----------------------------------------- I ----------I------------------------------------------ -------------------------------- -------- ------------------------------- 1�e work will be done in accordance with San Joaquin County 1�1 have prepared this cation and th#'f ve I hereby ce tiy thaf)� have I "'y laws, a rules s f the San Jo ui Local Health District. ordinances, S4talaws, ap I d rules�an e a n ------------------ and/or Contractor) Signed . ------ --------- -------- ---- ----- ------- -------- ----------------------------[Title)-------------------------------------------- ---------------- By:--_---------------- ........... ------------------------------------------------------------- (Plot plan, showing size 4 lot location of system in relation to wells, buildings, etc., can be placed an reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--"-.--.,f t;r-/11-------- ------------------------------------------ D E------- ---- ------ 11! DATE._ ............ --------------_------------- REVIEWEDBY--- ................F---------------------------------------------------- ----------- ------------- I�ATE---------------;e----------- -------------------------- Ill - 0 BUILDING PERMIT ISSUED------- and/or r ------------ 4 -------------------------------------------------------- --------------------- ------ ------------------------------- ------------- --------------- - ---------------------- ------- ---- --- -------------- ------------- -- ---------------------------------------------------- ------------ - ----------------------------------------- --------------------- --------------------------- ---- ------ --------------------------------- ---------- -------------- --------------------------------- ----------- ij�l FINAL INSPECTION BY:------.li4 ------------------------- Date-------IF/ - -------------------------------------I------- --��--- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California 11 Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 2M 5-62 ATLAS