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(0 . APPLICATION FORSANITATION PERMIT Permit No. ....1-e<_�.�_ {Complete in, Duplicate} This Permit Ex ires 1 Year From Date Issued Date Issued __-- �/--------------_- 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 Ordinance No. 549. JOB ADDRESS AND LOCATION- -------------5-'7o4 L2o��4�C�`l!t/ C ---- -- ---------------------------------- Owner's Name--------------- �c--• -----•--•----- Phone-fQ y- 7kI• ---------------------------- Address---------------•--•-----•-----------=----1-9��1 �•---1 �.61�------•--------- - Contractor's Name______________ ---------•-•-----------------------------•----= .-------------------------- -------- ____________•_ - i I :--------•---------•----------- ----------------------------------------- -- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial.❑ Trailer Court ❑ Motel ❑ Other Number of living units: --1--- Number of bedrooms _--3, Number'of baths-?�Lot size �___�_¢ ❑ Water Supply: Public system ❑ Communitysystem y ❑ Private a Depth to Water Table ---_--- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay% Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ NoNew Construction:• Yes No [] FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank+or cesspool permitted if publicsewer is available within 200 feet.) ° Septic Tank: Distance from nearest well_-_ b_f_Distance frqVTj foundation----�_ __,Material--__eo CR e— Na. of compartments^_ ----_-7:-----_--Size/�--J�-- __ __ --------------------- A Disposal Field: Distance from nearest well_., Q--f-pistance from fou Liquid de}�th--------------rf ___--_-Capacify---,(.ZCX7---.--- ndation----jo __--Distance to nearest lot line-- f--- Number of lines-__---•__- Lengthtof each line7--------DC7X___-'-_--.Width of trench----- -f.-. ------- -- of filter material � -----Depth of filter material_rc k_l ��-------Total length--------��,�--------------------- Type Seepage Pit: Distance to nearest well- --------------Distance from foundation--_....____.._,_-_.Distance to nearest lot line-------.--___-__ ❑ Number of pits_..__I---------------Lining material__« -__ Size:}'Di . arneter.- -:---.Depth -------------------- Cesspool: Distance from nearest wail-____-_f--------Distance from foundation___;_____- - --:Lining material------------------------------------ El Size: Diameter------ f-------- - _ Depth -- - --- -- ------------ - iqid Capacity- - i i - L nearest well Distance from nearest building------------- gals. Privy: Distance from ----------------- El Distance to nearestlot I ne------- ------------ Remodeling and/or repairing (describe)-------------- CJ = "' r - tt - ------------------------- . - ---•----- ---•----------- _ -----••----- }� n 'c jt t r' E r,I ' t :, f --= ------' ��. .+• -f _----_-_ ! --- ---:-'--•-_-_ ---- -- _h2-- ----------- ----------------- - - { 1 - -----_-----------------------------------------------------------------------'------------------------------------------------------------'----------------------•-------------------------------__--------- I hereby certify that I have prepared this application and fhat 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. 1 . 4 (Signed)•-- =f' ±' 'f. '� ► -------------------------------------------------------(Ow t ,�"-" -^'-- (Owner and/or Contractor) By----------------- ----- /__ i actor) {Title)------------------------ ---- - ---- -------- (Plot plan, showing size of lot, location of.,system-in relation to wells, buildings, etc., can be placed on reverse side). _...w- ... .. _ ( FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _ �lTREVIEWED $Y l i-------------------•--------------- ------- DATE------ - ----- ----- "7� ----- �--- ----- ----------------------- -- ---- -- DATE--------------------- UILDING PERMIT ISSUED - ------------------•------------- ---------•---------------•-------------------------------------------- DATE Alterations and/or recommendafions----------_----- ------------------------------------•- ------------------------------ ----------------------------- --- ---------•------------- FINAL INSPECTION $ - - -- - '---- ----------------- Date--- r SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stoci+on, California Lodi, California Manteca, California Tracy, California E$-92M Revised&'59 F.P.Co.