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--�.• FOR OFFICE V E• ,� "�-' � " Z __- Permit No. APPLlCAT10N FOR SANITATION PERMIT --------��''---` -------------------- ----" - -- -------- ---------- [Complete to Duplicate) Date issued . This'Permit Ex ires 1 Year From Date Issue --- -- ---- ------- --- Applicefiion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work he described. This application is made in compliance with County Ordinance N JOB ADDRESS AND LOCA ¢ ------ Phone._ •- ---•--•----•- ------ _Owner s Name-------------- --•- ---- --_---•- Address -5 (11U�° --------- ------------= 77' Phon _k-••-- ,Contractor's Name----------------------------- --•--- •--- •- - -•------.Q� � -= _..---•-------••- -•- Installation will`serve: Residence' Apartment House ElCommercial ❑ Trailer Court El Motel C] Other ❑ f , Number of living units: �_ Number of bedrooms .i�Number of baths ______._ Lot size :___DO---.---•.----•- •- ---------- Water Su I Publics stemCommunity system El private ❑ Depth to Water Table .1(5-ft. PP y' y •f - Cla Adobe Hardpan ❑ Character of soil to a depth of 3 feet: Sand n .'Gravel ❑ Sandy Loam ❑ ay Loam ❑ ClY ❑ I 4No FHA/VA: Yes F] No ❑ Previous Application Made: (If yes,date-------- "NoP New Construction: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: '6i, (No septic tank or cesspool permitted if'public sewer is available within 200 feet.) .k ---------------- Septic Tank: Distance from nearest well_'__:------------Distance from foundation_ulP__ae eh_ Material.--- Capacity----------------------- e,C1S�rh'T No. of compartments---------=---- -----------Size------ ------------ - q R F '50Disposal Field: Distance from nearest well-/LFII Distance from foundation_ p_____.____.Distance to nearest lot line/-------•------•-- tr Number of lines___ s-��,> -------Length of each line- _30. ---if Width of trench__ -.- --------- s❑ Total length--------- Type .--- - 4 Type of filter material_ _ <_ ____Depth of filter material____L__ ____________ f Seepa' e Pit: Distance to nearest ell--/ 6) �r Distancerom foundation_. -•---Dista ice to nearest lot lineF. ------- Number of psis-._ ��_ Lsnsng material-- --- ---Size: Diameter___- ----------.Depth__ - ----•---------= } i .gS Cesspool: Distance from nearest well;__-:___-------Distance from foundation._.________-_.____.Linin material.----------------------------------- - Size: Diameter----------------------- -;I- '-Depth }_--_--a------ ----------------------------fLiquidTCapacity.. g ❑ , I Privy: ` _-----------------Distance from nearest building------------------------------------------ Priv from nearest well-_''________________________ ...... 1-_' •- -----------------•--------------------- Distance to nearest !ot line----------------------------------------------------------------------------------------------------- Distance - ------------------------------------------ ----•---- --- ------------ --••---•------------ -- Remodeling and/or repairing (des�nbe)-------------- ------- ------------------ ------------------- -------------- . t --------•------------------ ---------------------•1-------- • = ..M -----------------••----------- '`�------=-------•-- I hereby certify that I have p:epar this application and that the work will be done in accordance with San Joaquin County ' ordinances, State laws, and r s!and r ulations of the San J in Local Health District. R �. (Owner and/or Contractor] ed ,`�--- ---: - (Sign. �-----------•--- ----------------- ----- -- G __AX2 4 t----•------- - -------------- BY--------:-------------- -------- -' ��.. . ------ - , �._ (Title) (Plot plan, showing size of lot, location of'system in relati to wells, buildings, a#c., can be plat on reverse side). FOR DEPARTMENT USE ONLY ( - '------------------------ ------------ DATE------- _.':---�.�' -�---�----- '---l--------- APPLICATION ACCEPTED BY__. -------------------- DATE--------------------• I REVIEWEDBY------------------------------------------ - ------------------------------------- ----- .. BUILDING PERMIT ISSUED-------•"----------------- - DATE Alterations'and/or recornmendatjpns: "" = ------------------ ------------------------Y .�� - ----- -y- -F _ f � Date-------- ----- --------- -•---•------- -,- --------- FINAL INSPECTION BY:. _ i . M� ,/t� I SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 124 Sycamore Street 205 West 9th at 730 5autfi American Sheet Trac Californiani Stockton,California Lodi,California Manteca,California Y. ES-9 AEVIOrD 11.69 r.B.rM 1H 6-60