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F R 71 ,C SE: -.� - ,- _ - APPLICATION FOR SANITATION PERMIT Permit No. ZZd._ � rf��6 � ------------------------- ------------------------------ (Complete in Duplicate) ----------------------- -------------------------------- This Permit Expires 1 Year From.Date Issued Date issued Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein described. ' This application is made in compliancelwith County Ordinance No. 549. JOB ADDRESS A LOCATIO .. 33 7` - --------------------•---................--•-•--------------------------------- Owner's Name... f n.Gst - - -•----- --•----------------------------------------- -----------=--------------------------------------•--- Phone....-------------------•------- Address__.-------• ------4 Z- � Y ; Con#ratter's Name I CS - --------------------------- Phone...............•--•---•---.._._.... Installation will serve: 'Residence Apartment House ❑.- Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑. Number of living units: �______ Number of bedrooms .: Number of baths /-_____ Lot size __ ............... .......... ...... I i Water Supply: Public system ,❑ Community system ❑ Private ET. -bepth To Water Table _:eaft. Character of soil to a depth of 3 feet:, Sand ❑ Gravel ❑ Sandy.Loam�❑ Clay Loam ❑ Clay ❑ Adobe a-i'lardpan 0 ++ Previous Application Made: (If yes,date____________________) No New Construction: Yes ❑ No 2-_'FHA/VA: Yes ❑ No E�—' I TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tanks within 200 Septi ankDistancefrrom pea ewell public sewerDistance from foundation feet.) founda ion -•----+ Material________________________________________________ j -- �No. of compartments ----------- `:; Size------------------------------ Liquid dap+h --- Capacity Dis.p I Fiel Distance from nearesttwell-_-_--__'�--_Distance from foundation___________________Distance to nearest lot line....._....... .... ,f Number of lines------- ___':____,�_______.___-Length of each line_______;__,.'..._._ Width of trench-----------_s= -------- _.: 1... k yp ,. : +: P. �. r g nearest I--- I `3'=�----- T e of filter matenal.:.,__. " ____be th.of filter material---1 _____________Totaf fen th___.___._ d___:_________ Seeps it: Distance to nearest wet rom foundation O--------------Distance toof e P ----Lini -g material.-- .0--.�� Size. Diameter- �. ---Depth--�•'•5�-----_ --- Cesspool: Distance from nearest well___________' Number of its________ ______ _ Lining __.__Distance from foundation--------------------Lining material_.-____.._.._____________________.`__ ; Size: Diameter------ ----------------- ----De th----------------------------------------------------Li Liquid Capacity als. - Privy: Distance from nearest welt----------------------------------------- q P ty_. _ g l y; --------Distance from nearest building------------------------------------------ Distance ------__-----_--_-_---__----_--_--- ---. ❑ Distance to nearest lot line------ --------------------------------------------------•--------------•------------------------•-••-----•-•----•-------•---•----- ------ Remodeling and/or repairing (describe):_____--_-___'__-__ `---" - i I ...........----------------------------------------------- -- --------------------•------------------------------------------------------ ----------•-----•-•--------------------•--•---------------------------------------- •-----•--------•---- ---- I - --- - -- ---- -- -•---•-------------- --- ------• ------ --------------- -- -- ------ - 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. I S( igned).. -------•---------------------•------------------ --------------------- :. = {Owner and/or Contractor] By-------------------------•--------------------=`_.--•°--.-----=---..__ .. =: - --•--(Title)------------------------------ ................... 4„ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY -- APPLICATION ACCEPTED BY_____--------------__ - +--- ----------------- ---------------------------------------- DATE----------�-=---e�/=- REVIEWEDBY -------------------------------------=------------------------------- DATE = '• BUILDINGPERMIT ISSUED--------------------------------------------i-------------------------------------------------------- DATE---------_.----------------------------------------------- Alterations and/or recommendations:- ------------------------------ _-- _•-• ------.------�---_---w� ------- ----------------- -------------------------------- -z--- ------ - •-- ----------------------------------------- -------- -----------=-------------------- ------------ --------------- ----------------------------------------- --------------------------•-------•----•------•----•--_-----•-•'--__ 1`lNAL INSPECTION BY: Date ---- -------------------------- - � -=--------------- �� 7 ' I SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Strout I 300 West Oak Senel 124 Sycamore Street los wool 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E9 9 REVISED 8-59 2M 5-62 ATLAS 111 ll