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F R OFFIC.TE: l � -- ------- - - APPLICATION FOR SANITATION PERMIT Permit No. ------------------ - [Complete in Duplicate) : (o i '0 Date Issued jl...; ___________________________-_.__-_______ This Permit Expires 1 Year From 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 Ordinance No. 5549. i JOB ADDRESS AND LOCATION--------- ---------- ------- Owner's Name-------------T ------- Address --•-- " Phone. Address-------------- 4 ( f l�aGr � ' a Contractor's Name--------- r- ..... .... .....t�t2 .1 ---- ........... � _------=-- Phone ��---- I Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court [3 Motel ❑ Other ❑ Number of living units: -_-7___ Number of bedrooms ____ Number of baths 1-. Lot size ---_-------------- Water Supply: Public system Community system ElPrivate E] .Depth to Water Table _fzoft. Character of soil to a depth of 3 feet: ''Sand-E) Gravel ❑ Sandy Loam [] Clay Loam ❑ Clay E❑ Adobe Hardpan ❑ l Previous Application Made: (If yes,date___________________) No,(-_KNew Construction: Yes ❑ No ❑ FHA/VA-. Yes ❑ No ❑ a TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic.tank or cesspool permitted if public sewer is available within 200 feet.) S tic` rrk: 4 Distance from nearest well-----------------Distance from foundation----.--------------Material______________-_________.__________-.__________- �/�f/Yf i',No: of compartments------------- -•------ Size-----••---------- ------Liquid depth--------------- -------•--Capacity------------- / \ Disposal Field: Distance from nearest well �Distance from foundation---;l49----------Distance' to nearest lot line-45....... G `,Number of lines_________________________ Length of each line--------.. �r_-___.Width of trench-._. -__- S�Type of filter material____ �t__.___Depth of filter material----/V-_________-.Total length_____,,z..Z......................... \ Se epa a Pit: %.SDistarnce to nearest well-__. _ —__Distance rom foundation.....1QI......Distance o nearest lot line_____~__ Number of-pits------/------------Lining Size: Diameter----- - ,...a,. tea.-.�,.- ..._....�.. 4 Cesspool: Distnce rom nearest well_________________Distance from foundation-.-.___________-_-_.Lining .. material. _-_______________...___.___.__.. ❑ tSize: Diameter---------------------- ----- ------Depth- ----------- ------- :-___Li Liquid Capacity----------------------------gals. Privy:. 'Distance from neariest well---- -------- ---_____________._____.____--Distance from nearest building________________________________._-__-- ❑� % ► �.. : W ,c:~� ....._. ---------------------------------- :1 %Distance t� nearest Ibt'line -------------- --------;-------------------------- -- ------ ------------------------------------ ---- ---- Remo ling and/-or repairing -- .� - , �- ------------- ---- ----•----k------- --- ------ ---- -- - - - ----------------------- --- ------------- -� .. ----------------- _: � � ---- -------- .��----------- Z� ------ I hereby certify that`I have prepared this�applicatio and that the work will be done in accordance with San Joaquin County ordinances, State rule n re lations of the San Joaquin Lo al Health District. ' (Signed)------ -� 4-- I✓C ✓- ----------------- (Owner and/or Contractor) ------ --- ----Title - '_-- (Plot plan, showing size of lot, location of system in relation o wells, buildings, etc., an be placed on reverse side). J ' FOR DEPARTMENT USE ONLY :I R r APPLICATION ACCEPTED ---------------------- DATE------rte'=' '-4 -------------------------- REVIEWED BY--------------------------------------------- --------------------`--- ---------------------------------------------- -------- DATE---------'---------------------•---••-------- ` BUILDINGPERMIT ISSUED-------------------------------------------------------------------------.._..._--- •------------ DATE-------------------•----•---------•--•- Alterations and/or recommendations_________________________ - �! ---------- ------ -- - ------ -•-----------------------•--- •----........... ---• ------------- ---•••------------------ --------------------------------•------------------ ------ --------------------------------------------------------------------------------------------------------------------------------------- -------------------------------- ---------------- ------------------- -------------------------------- ------------------------------------------------------------ -----------------------------------------.---- FINAL INSPECTION BY:------------`- --`--.-. ----------------- -- Date------ -------------- -- 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 r5,9 Rrvisro 6-59 i.P.CO.2M 6.6c