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FOROFFICE USE: --------------------------------------------------------- APPLICATIION FOR SANITATION PERMIT Permit No. -------- ----- -------------------------------------- (Complete in Duplicate) Date Issued --------------------------------------------- This Permit Expires 1 Year From Date Issued .______.__�._ � r3 -- rao �-i� Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein describe _ This application is made in compliance with Count 0a sJNo. 549. JOB ADDRESS A LOCATION._. _ -- . 1 1 T H �.(✓•-- ' �-t Owner's Name---- -- ---------Me _.. .. E �`` �j -=--------• - --I------- ------------------ Phone._Y_--- 2.0-5_- 7 Address....... -p jy ---- - -------............................_-......... Contractor's Name----- 3. ......fj- A-.- "'�r ��---'----- .... ..----------------------------- Phone................................I Installation will serve: Residence Apartment House ❑ Commercial ❑ . Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J-___ Number of bedrooms AV. Number of baths --5-- Lot size ---- ----------- ___________________•-___:.._ Water Supply: Public system ❑ Community system ❑ Private RT' Depth To Water Tabl%'_10 ft. f' Character of soil to a depth of 3 feet: Sand ❑'Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: {lf yes,date------------ _._:_'._} No New Construction: Yes [ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permittedf public sewer is eilable within 200 feet.)f Septic ank: Distance from nearest well_____• C',_.--Dista i e from foundation,---f11----__-----Material------- _/---------------..-----__..___.._.. No. of compartments'-----�-------------Size_ e` --�----�•�-�--X�'Liquid depth----�-�----- - - --..Capacit7+--l —,�- i f Dis osa ieid: Distance from nearest we I_-R��'--l-Distance-`fr m"foundat�o -----------Dis#ante to nearest lot line•.3 _-..-._. ^, p Number of lines..,..----- of each line._____ L7_�_________-..Width of trench.,._,2_"___ -. cep Type.of filter,material----t�1:-OVJ;.�----Depth of filter-rnaterial......IT--`--_-Tatar-length------ ___ __________________ Dist Seepage Pit: Numaber of nearest well--------------Linin mDateraialce from founds ze:nDiameter-----------------------Distance to nearest lot line----------------- Number ------------- +, � Cesspool: j m Distance,fromearest well--------;_-------Distance from foundation--------------------Lining material..--._____--___________--•--- a ------Liquid Capacity❑ Size: Diamefee �4--------------------- Depth - A 9 P tY gals. O ., Privy: Distance from nearest well--------------------------------------------_....Distance from nearest building--------------------------.._............. ❑ Distance to neaiest lot line----------------------------------------------- -------•-•---------- ... .... --------------------------------------------------------- Remodeling and/or repairing_(describe):----------------`-------------------------------------•-•----------------•--•--•---------•-------•------ ----------•---•. --- ------------------ -. ---------------•-------------------------------------------------------------------------------------------...-•-•----------------------•----------------------------------------------------------------------------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (S -•--- --• -- ----- -----------------•-•. .•� �d/or Contractor)igned).............. - - By:-------- --------- -----------------------(Title)---------------------------• -- ------------------------------- (Plot plan, showing size of lot, location of system in relation to wells buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY ' ----------------- --•------------------------------------- DATE.../ '3- ' REVIEWEDBY--------------------------------------- ------------------------------------------------------------------------ DATE----------------------------------------------------------- BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE--------------------------------- Alterations and/or recommend'ations:------------------------------------- --------- --------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------- ------------•--- -•----------------------------••---------------------•---------•------••------------•---------•------------•-•••--------------- ..........................................................---------------------------------- ------ ------- - -----------------------------------------------------------•-•----------- __---------------- -------------- FINAL INSPECTION BY: �� Date__.«_", - 5 . SAN JOAQUIN LOCAL HEALTH DISTRICT � k 130 South American Street 300 West Oak Street sn �� 124 Sycamore Street 205 West 4th Street Stockton,Californla r Ja "Lodi,California `'° -Manteca Caiifornla r Tracy,California ES 9 REVISED 8-59 2M 5-52 ATLAS 11 i