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FOR OFFICE USE: -------------------------------------- ---------------------------- APPLICATION FOR SANITATION PERMIT Permit No. -11 -. (Complete in Du�'licefe)r `� ' �� 7--� 7Flis Permit Ez ir"is-1,Yeac,.From Dat.e_�ssued Data Issued _______________________ Application is hereby made to the San Joaquin Local Health Distrid,for a pe-tmTit to construct and install the work herein described. This application is made in compliance with County.,Ordinance No.-549r' JOB ADDRESS AND LOCATION._1_I_,_5. t ----- -r-•-- Z--Z--3K04 �. _ Owner's-Name � �q S - .�. _/ Address._---------- Contractor's Name.. l ..Y�... ._ 1.. - - ._.....__ Phone----------------------------------- Installation ------------- - ---- ------Installation will serve: Residence a Apartment House ❑ Commercial ❑ Trailer iLourt ❑ Motel ❑ Other ❑ Je Number of living units; __1__._ Number of bedrooms .,�_ Number of aths ' Ltlot size -_�_.y _./ ._. ..,� ______________ Water Supply: Public system ❑ Community system ❑ Private Depth T1N er Table Fes__. ft. Character of soil to a depth of 3 feet: Sand ravel ❑ Sandy Loam Clay Lot m ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (if yes,date-----------.-------I No New Construction: Yes RKN`o ❑ FHA/VA: Yes ❑ No TYPE._OF.INSTALLATION AND SPECIFICATIONS: « (No septic tank or cesspool permiHed,if pu6Gc sewt3r i`arailabl within 200 feet.i) Septic Tank: D-isance from No{of compartmentst well------�,---_Si can ewfro�mr`�`f�o`undatiLq d—dept` Material_..-------�--•---------------------------- h-------------------------Capacity----------------------- ON Disposal Field; Distance fro neo es. well -�-- Distance_,from•foundation...: w -------Distance to nearest lot line... .......... 4— Number of;lines'^ i- _ ngthf'each line ` .""'":.Width of +ranch_________` (�_f............. Type of filter materlal-=��- K-=.DEpth�o -filter-material " _ _ _ .-Total length-------------3-S_-___________--__._ Seepage Pit: Distance to nearest well______________________Distance from foundation____-___ ......__-.Distance to nearest lot line................. ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----.----._--.---------Dept h----_------------•--------.------ �+ Cesspool: Distance from nearest well_________________Distance from foundation.....6 -......Lining material________________________----_______ ❑ Size: Diameter------------ -------------------------Depth-_---------=---------------- -------1-----------Liquid Capacity----------------------------gals. Privy: Distance from nearest well_________________________________________ ______Distance rf om nearest building------------------------------------------ 0 Distance to nearest lot line Remodeling and/or repairin.g (describe):...-,.,_._........:.� __� ..: -----------------•------------------- q --------------------------------------•--• ---------------------------------- -------------------------------------- ....--------------------------- t ---------- ----------------------------,�--------------�_-- �•---••...d ----------------------------------•----------------••-------- ----------------••------ ---------------------------------------- - ' Q- ;l•= --- � I Q I I hereby certify that I have prepared this application and tha# fhe,work will-be done in accordance with San Joaquin County ordinances, St laws, an� and ulations of the San Joaquin"`L'ocal'`He"alth YDistri�t. ' (Signed) ------ � -- ------------ -------------------•--•------------------------------- ______________to and/or Contractor) _ By:_-------..—_' -= -_•----_--- �- = --------------------------- -----------------------------------------(Title)-•----•----------- (Plot plan, showing size of lot, location,of=system•in=relation•to-wellsr buildings;,etc.;can•be-placed-on-rereFse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY... ----------------------------------------------------------- DATE-•-- = REVIEWEDBY------------------------------•------------- ----------------------------------------------------------------------------•--. DATE BUILDING PERMIT ISSUED............... -------------- --- DATE _ �_ r, � .. ..... ........r.�... ._-. ANFeration end c5r'recomfnirnda"Fions.- - -- -sl - - - ---•------------ ------------------ C> ... ` �...........:.�1c_ Y ..._Oi1j- �- ----�R_ . _SNo ....._.. RM r —1---------..- ----------------------------------------------•---------------- ----- ----- : ____ _ __________________________________ _ FINAL INS TION BY: r _------ _-- / Date-------- --`�T-`..C? i SAN JOAQUIN LOCAL HEALTH DISTRICT { 130 South American Street 300 West Oak street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED t3-59 2M 5-62 ATLAS