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g PermitruNo. ..: �G ----• APPLICATION FOR SANITATION PERMIT / (Complete in Duplicate) Date Issued ..�`�-J-. 6---• i 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.'549: i------- ----•-------------•---------------- JOB ADDRESS A LOCATIO - 0 ------ ,--------F&oz___t4----- Owner's Name________ -__-- = l 4`_S.l. , ._ Phone_..__«---------------------- as �� - -------Address ` ---------------------------------�---------------------•-•----- [ 41 L�` 4�r)_��Z-�.l phone -_ Contractor's Name__;"____ / Installation will serve: Residence [RL Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___L_._ Number of bedrooms J--__ Number of baths _ _-(-_ Lot size .__ k- ----------------•----------------------- Water Supply: Public.system 54- Community system ❑ Private ❑ Depth to Water Table 4- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe gL Hardpan ❑ Previous Application Made: Yes ❑ No%L New Construction: Yes ❑ No o1, FNA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: _:Distance from nearest well----------------- from,foundation ___________________Material-_____________.___-___-_____________.-________-_. ❑ No. of compartmen#s_- Size "----Liquid depth----------- --------------Capacity----------------------- ti Disposal Field: Distance from neare well__._----Distance from foundation---10________--Distance to nearest lot line___.-..--__ Number of lines_----a---- --- ------ =------Length of each line_�_t_a�+�{r__-Width of trench__._2 ---.-----------------•-- Type of filter material____r--- --- ---------Depth of filter material___-� ___-_-Total length--------��l?=_;-------.-------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line____.-_____.____ ❑ Number of pits----------------------Lining material---------- ------------Size: Diameter----------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__.-______-___--__-____--_______-__. V ❑ ----------Depth---=------------------------------------------------Liquid Capacity------------------- -------gals. Size: Qiameter- ------------------------ Privy: Distance from nearest well----------_------------------------_--------------Distance from nearest building________-_____---_______-____---.-____-_- ❑ Distance to nearest lot line---------------------- - ----------------------------------------------------------------------------------------------------------- t I Remodeling and/or repairing (describe)-------- ------------------------------------------------- ----------------------•----------- -•------------------------- --•------ ----------------------------------------- -----•--- ------------------------------------------------- ---------- ------------------------------------------------ t ---- ------------------------------ --- --- ------ -------------- -------------------------------------------------------------•------------------------- ; I hereby certify that I'have prepared is application and that the work will be done in accordance with San Joaquin County ordinances, State laws, a rules and re ations of the San Joaquin Local Health'District. (Signed) ----- ------ -- ............. {Owner and/or Contractor) ----- - --_-:-----(Title)-------------------------------------- -. ------ -------- -------------------------- (Plot - - - - -........ -(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 ----------------------------- APPLICATION ACCEPTED BY-------- ------ DATE--------------Ep ----------- -- W- ------------------------------------------------------------ ---- ---------------------------------- REVIEWED BY------------------------------------- -------- --- � ------- _ DATE_--.,------- ----------------------- ---------------- BUILDING PERMIT ISSUED-------------------------- DATE Alterations and/or recommendations:------------.--------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------- f? 1""' FINAL INSPECTION BY: •-_* _.___ .�Gi3------ ---- --------- Date ..'f - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 S afh American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E$-9-2M ReVLSed 8-'59 F.P.Co.