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FOR OFFICE USE: r ---------- - Permit No...._1. ------------------------------------------;.APPLICATION FOR SANITATION PERMIT --------------------------------------------------------- ----.- (Complete in Duplicate] Date issued / A/ ------------ ----- I -------------------- '^ —1 --This Permit' Ex ires 1 Year From Date Issued.". ----------------------------------------------"-------- Application is hereby made to the San Joaquin Local Healfh District for permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 54 . I ------ - ----' -- ----r---------t..'. ------- JOB h ADDRESS AND LOCATION..�( -- u ---- Phone.-- - •----•--- Owners Name ----------------- ��•:----, Q -•z_:_ = ��-------------------------------------------------- -�. Address {' ` �._.. - Phone.. •-�Q-- --- - I I Contractor's Name --------------------Qt"} lid---------------- ---- -•----•----------- Installation will serve: 'Residence ' Apartment House 'Commercial,,.[] Trailer Court ❑ Motel ❑ Other ❑ %I p ❑ Number of living units: -f Number of bedrooms __-/7__-Number of`ba+hs ____I - Lot.size --- �0_-----X`��. j It. t Water Supply: Public system Communitytsys+em ❑ Private ❑ Depth to Water Table t -____ ft. f y Adobe Hardpan Character of soil to a depth of 3 feet: Sand ❑� .Gravel ❑ - Sandy Loam ❑ Clay Loarn �K Clay ❑ ❑ ❑ Previous Application Made: (If yes,date____________________} .No New- Construction: Yes ❑ No I FHA/VA: Yes[_ No TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank{or cesspool permitted if. public sewer., is available within. 200 feet.) _ 1 Aji A_ -Mat st well._ Distant f{o f9unda��on_ -- Septic Tank: Distance from neareCapacity ' 't -Sized �f Liquid depth dry p tY No. of compartments__-_"-��----- P t t Dispo I Field: Distance from nearest well_�Distance from foundation r Distance to neares�l�, line.__��_ "- F \ j�� Number of lines.---- •-------------------- Length of each liFne_:_---_------t"1.1+_5_.__.Wid#h of trench-___-- - -----.------------------- ` Type of filter materiai____�� Depth of filter material___ �,�____ -.----Total length_."-"_____"��--�--------------•---- C -�. Seepage Pit. Distance to -nearest well _______________----- f_D•i$tance from foundafiion____.______.-*___.Distance #o nearest lot ins____.__.___.__._. Number of pits: -"-------------- Lining material,---------------- ----.Size: Diameter--- ---- _. 7 .Depth---------------------••---------- ❑ i .. k Cess ool: F ; I N `Distance from nearest well -_-____________'Distance from foundation_____-- _.___- __ Linsng "material__-____.:"__:: ________ej5. p Size D-iameter� ' ----,Depth---------------- # ----- Liquid Capacity 9 Distance from nearest building ------------------------------------------ ist Distance from nearest well-""__-_-___:___":_-_---__ ❑ Distance to nearest.1of line. -------------- - =---------•----•----------------------------------------------- ----- I Remodeling and or repair' g ids ribs}:------ -_-- - -- ---------- i -�----- GZQ� - - - --- - - - -- -- ---- Kf /prepared P.c: pp - - - ------ I 'her - e - b certifythat ave re ared this a lication and that the work will ---"�-- "be done in accordance with San Joaquin County ordinanceXSfto laws.' and rules Ind regulations of the San Joaquin Local Health District. G' _:_(Owner and/or Contractor) (Signed)----- __ 1- +------------:----------------- ' ---------------------------------- (Tit --- - ---- e_ (Plot plan, showing size of lot, location of system in relation to wells, buildings,"etc., can be placed on reverse side). t -s FOR DEPARTMENT USE ONLY F = DATE---- -- --�•:- i APPLICATION ACCEPTED BY s________________ ------- - ----- ---- -- ---------------------- REVIEWEDBY --------- 1-----•------------------------------------------------------------- •--------:----------------- DATE. - -------------- BUILDING PERMIT ISSUED ------------- ----•---------------------------•---------------•------ DATE._..._.. - Alterations and/or re�'mmendations:�_: = J= -- �! �� p/1 . ,p --------------------------- ----------- --------------------- ----------- 7 ---- L ------------------ --------------------- -------------------- ---- ------------- ----------- � ------------------- FINAL INSPECTION BY:----_-.--- -"----- --- --�--------------------- Date • - --- I SAN JOAQUIN LOCAL HEALTH DISTRICT 30 South American Street 4 300 West Oak Street ] 24 Sycamore Street 205 west 9th Street Stockton, California i Lodi, California Manteca, California Tracy, California E6.9 REVISED e•59 F.P.CO• ZM 6•E4