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FOR OFFICE USE: �/.�. ..................... .......Y �`APPUCATION FOR SANITATION PER Permit N_121-11 � MIT o. .....-- .. ------... ........................ ------------- --- i 141f°1-r°�'' (Complti'fe in Duplicafe) This Permit Expires Y Year From Date Issued Date Issued Application is hereby made to the an Jo�Local Health District for a permit to construct and install the work herein described, This application is made in compfjritfTCbunty Ordinance No. 549. JOB ADDRESS AND LOCATIONy.--G'fh.1"P..Y1_..ti4Aw`'_-.hnA`�_..tIQ�sP� ....... Owner's Name.............Q. ... �..�........ `e r ........ ....-"---- . ....................................... Phone ............................ ........ Address--------- ---- �c.>{v.. 1�Q.-O_h-•`,�..... 0!�.�. C� ~ Contractor's Name f _lp r- .Q Y-. . .....Q..4 fve—`p.."�-...�Al.._Y��.........:.::........ Phone ............... ....... Installation will serve: Residence Apartment House ❑ ,Commercial ❑ Trailer Court [] Motel ❑ Other ❑ ! Number of living units:..... Number of bedrooms J.... Number of baths ........ Lot size _.aof/f,�. r Wafer Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table -7_-_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ _,.Clay E] Adobe [Hardpan ❑ Previous Application Made: (If yes, date ................."..) No Igo" New Construction: Yes ❑ No (� FHA/VA: Yes ❑ No [� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well.;$.A ........ Distance from foundation... / .) .. �.•..._-..Material. ................. ..�•--------.._......... P9 No, of compartments ........ a ....... /_..Size-..-X..-ir__X.q'...Liquid d`pth......... ��f __Capacity__._$..%�:��.Q+/, i Disposal Field: Distance from nearest well__.,'�D....... Distance from faundation..10.�__..._.Distance to nearest lot li� .._...�._..._.... Number of lines ....._._......_.....-Gf.1. Length of each line._,.......$Q----)7..,;.Width of trench ...__.._._ r Type of filter material.gQ,A,�d-.T4.--Depth of filter moterial_ _.;_f 17.._......Total length ................ ........... �.} Seepage Pit: Distance to nearest well .. ...................Distance from foundation .................... Distance to nearest lot line ------- .......... ❑ Number of pits ...................... Lining material....... .......... :.--..Size: Diameter ............ ........... Depth ................ ....... '._. ._.. Cesspool: Distance from nearest well.................Distance from foundation .................... Lining material ............................. ❑ Size: Diameter ..................... .............. Depth. ...................................... _....----.... Liquid Capacity .................. ....:--gals. Privy: Distance from nearest well ....... .------------------------ _............. .-.Distance from nearest building... ........ ...................... .._..__.. ❑ Distance to nearest lot line ........... ..................................... ---......-"-----------------"-------._..............._...... ...................... Remodeling and/or repairing (describe): ................... r i 3 ....................... ............ _................... ............................................. - ..--•--•-------------------------------- Z __. --............__..........--•--- 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) X t .:.:..1 ..._- -------------- ------------ ------------ --- ..__.-........... --------(Owner and/or Contractor) By: ................ ................ .............................................................................................. (Title) ................... .._..-- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE APPLICATION ACCEPTED BY ....... ...... ?l.r/./`�'� DATE..'.. REVIEWED BY BY_........................�--........................... .........._...--................... DATE ................. ............... ............................ BUILDINGPERMIT ISSUED-....._--------------------------- ----------"------•------- — ----- ........... .............. DATE ............................................................._ te ations and/�opr ryec�om,ccmendations:.................... ..... ... ..` _....... �.,;. Q. l�I •..! - /1� .rs C.:.G.N �M.�a.Gl�.[ �k�!ttiL.._ ` <!Ze,A �[tk..6l... c!------ ----- lS! Ctt�fit.,..te 1a' ............ ..� ......-W-1z"--------------------------•--•--••"•-:-•-- .... :.......................... -.............................................................................. .................................................................................. .................•........_... FINAL INSPECTION BY: ....... r.x,.x� .................................... SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. Hoselten Ave. 300 West Oak Street 124 Sycamore street 205 West 9th Street Stockton, Callfornla Lodi, California r`+ Manteca, California Tracy, California E9 9 REVISCO 0-69 3M 3-•63 F.P.CO.