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FOR OFFICE USE: �36 3 � 5 � �1 --------------- ----------------------------------------- / �7 r AveLICATION FOR SANITATION PERMIT Permit No. -1-.� 7�f.. ...................... ------- (Complete in Duplicate) ---.--- This Permit Expires 9 Year From Date Issued Date Issued .��- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordi nce No. 549. 64 JOB ADDRESSID L C TION + ---------- - ---"'- -------------------------------------- Owner s Na e-- ------- Phone------------------------------------ ** -------- ---- --- - - ---------------------------------------- Ad ss- t � - ------ -t-- - � /` vv Contractor's Name---------------------------- - `' G{ - ---L"---- --------..- Phone.. Iv = Il-. -. . Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court Motel ❑ Other ❑ Number of living units;,,,,,__ Number of bedroom--- Number of baths- Lot size -__ --._ _____�� Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table t. Character of soil to a depth of 3 feet: Sand Gravel Sa dy Loam ❑ Clay Loam ❑ Clay ❑ dobe1-lardpan ❑ Previous Application Made: (If yes,date.- . .�_V.Y of New Construction: Yes E] No FHA/VA: Yes E] No ❑ TYPE OF INSTALLATION AND SPECIFICA ONS: (No-septic to esspool permitted if public sewer is available within 200 feet.) S&T Distance from nearest well-----------------Distance from foundation----------------....Material------------------------------------------------ . -�Noo.. of compartments---------- ---------------Size---------------------------- ---Liquid depth-------------- Capacity----------------------- s_aI elm Distance from nearest well Distance from foundation--------------------Distance to nearest lot line----------------- Number of lines----------------------_-----------Length of each line------------------------------Width of trench----------------------.--___------- e of filter material-------- ...... , Depth of filter material---------------..Total length___.-.-----------_-------------------. �;pa�ance to near t well_-- -_ ------_.Dis a �� to nearest lot ne------ -- ---_ Distance from foundation---� A Number of pits.-------------Lining material-e.� ---.Size: Diameter.....�d----------Depth------.ACS------------- pQ Cesspool: Distance from nearest weli-----------------Distance from foundation--------------------Lining material----------------------______--------- ❑ Size: Diameter------ -------------- ----------------Depth-.-------------------------------------------------Liquid Capacity- --------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest buifding------------------------------------------ LA ❑ Distance to nearest lot line--- --------------------------------------------------------------------------- -------------- ----------------------------------------------- Remodeling and/or repairing {describe)------------ -------- ----------- ------------------------------- ------ --- --- -- ---- -------- - --- ------ - --------------- --------------- ----- ------- fir"`-'-•- ---- -------- - `- ` f- - - ---------- 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, yrules and regulations of the San Joaquin Local Health District. (Signed)- ��--�Ii- - moi J7 �S ------ --------- tract on or SERVICE Sy;--2915 -Mineravv@K Haj 3 4l--------------- ----- - - - - - - - -- -----------Title-- ---=---=- ----_-----...------ - --------- _._.-,,.:--- (Plot plan, showing size of lot, location of system in relation wells, bui dings, ic., can be placed on reverse side). FOR DEP RTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------------------------------------------ = (C DATE ' -. REVIEWEDBY-------------------------- ---------------- --------------------- ---------_------- -- ----- --------------------- DATE BUILDING PERMIT ISSUED---------------------------------------------------------------------------------------- ------------ DATE----------------------------------------- Alterations and/or recommendations---------------------- - --------------------------------------------------•-----------------------------------•------------------------------------------------ --------------------------------------- ------------------------------- ---- - ---- -------------------------------------------------------------------------------------------------------------------------------------- ---- ------------------------------------------------------------------------------------------------------ --------------- --------------------------------------------------------------------------------------- FINAL INSPECTION BY .- '- :,:_ __.. '' ✓/` ------- Date .- .. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9Th Street Stockton,California Lodi,California Mantecar California Tracy,California r•.a.c o.