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FOR pFFICE.USE: f -------------------------------------------------------- -- - ----- ---.-_ APPLICATION FOR SANITATION PERMIT Permit No.'_______ ______ _ ` (Complete omete in Duplicate) y7/4 Date Issued =------------- This Permit Explre_s i Year From Date Issued Application is hereby made to the SanJoaquin 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. M� 14 mal P .�.�p' JOB ADDRESS AND LOCATIM—__. b___::_!, > T:_=C -------f: Owner's-Name------- - 4EV_iE-N_6_F_-R--------P.F_1_F)1r' -- --r------------------ one Ph,.. Address--- : -363---- C - ----a =_ ----------- Contractor's Name_fi1h_(,,ATF-cam=----- � ---------------- ----------I,Phone-------•--------------------------- Installation will serve: Residence Et—Apartment House [] 'Commercial E] Trailer�FCourt ❑ Motel ❑ Other (] g Number of,,bath- � -- Lot size ------.Number of living units:._ _ Number of bedrooms•r-_ -__-_._----_ t Wafer Supply: Public system#❑ ° Community system i--]"!Private , Dep h to Water Table _. -_ ft. Character of soil to a depth of'3 feet: Sand Gravel[ ] Sa dy Loam [:] Clay Loam E] Clay ❑ Adobe E] Hardpan ❑ Previous Application,Made:_(If yes,.date--------------------} No Z3-'.--New Construction: Yes �o E❑ FHA/VA: Yes ❑ Noe' LOW TYPE OF INSTALLATION AN--,,SPECIFICATIONS: No ctan P-se tik-or..cesspool._permittr i ed.ifrpublic.sewes..available within-200 feet.)-. . r IJ `+.,^J Septic Tank: Distance from nearest well___'____._____Distance from foundation__________________Material____._._________________..______..__-_...__.___. El No. of coml3artments---------------4*-.... Size-------•---------- -------------Liquid depth_---------_--------------Capacity-,---- ------ Disposal Feld: Distance from nearest well---._:._-Distance from foundation-----/0--------Distance to nearest lot line---- -_—_-------_-_1Length.,ofreach line____�0_-__c-______._.Width of trench--_-. -.-'_______________ AD� Type of filter material-_ -Ck'�_,__aepth of flier material----/�_-_____Total length------ ____ rx r5,-�— Seepage Pit: Distance to nea st well_______________________Distance from foundation.._....:.--- to nearest Idt line._._._-_________ Ill ❑ Number of pifs--•--- ---------------Lining material--------- --------- Size: Diameter----------------------Depth--------- ---------------------- v Cesspool: Dittarfice from nearest well ------- - Distance fr om foundation--------------------Lining material-_..______________ ❑ Size. l3iameter Depth`':: Liquid Capacity-..--- -------- gals. Privy: Dlstance,from,n crest w_ ell _______________ _____________ .--------Distance from nearest building—,___________---_. ClDistance to nearest lot line----- ------------------ --`--------------------------------------------------------•----------------------------------------------------- Remodeling ----;----------Remodeling and/or repairing (describe)______________________ r1 Ila --------•----------------------------------------------------•--- - -------------------------------------- ---------------- -- -----------------•---•--------------------•---------------------------------------------------------------------------------------------- --------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Staf laws, and rules a 'd regulations of the San Joaquin Local Health District. - (Signed) f -------- -------------- ------------------ r----(Owner and/or Contractor) _ Gtcy� - . . t �Y_ r -_--------------{Title} ------------------------------ Pi Pot n s-h w ng i a of I t o a on of s st m in relation to wells;buildm s etc.;Gari be laced on reverse side L FOR DEPARTMENT USE ONLY. APPLICATION ACCEPTED BY-- t-' -t.-�--- -0- --------------= --------------------------------------------------- DATE,.... " REVIEWEDBY ----------------------------- ----------------------------------------------------------- DATE---------------------------------------- BUILDING PERMIT,ISSUED ---------------------------------=--r----=-------- =---===------ -----=-------: ---;DATE-=--= ------- Alterations .-Alterations and/or recommendations:----------- -------- ------------------------••----- -•--------------------•------------------------------------.-------------------------------------- l 0 t - iiJ� ----------------------------------- -------------------------------------------------------- ----------------------------------------------------------------•-------------------------------------------------------------- FINAL INSPI6AJ_I3Y. Date---------------- S SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-S9 3M 3•'63 F.F,03.