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FOR OFFICE USE: --------=-------------------------------------------- ------ -------------------------------------------------- ----------- ------°--------------------------___...._____.._____._. APPLICATION FOR SANITATION PERMIT Permit No. ............ (Complete in Duplicate) - - ------,------ £This Permit Expires i 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 Or rn- - e*No. 549, �:�:,�.�P,,� ��--mss f � - �S�Lon► J08 ADDRESS AND LOCATION '' rl / 1�•� �-]/- '� �1'T .l_ Owner's Name..........5..c �' N -------------------------------------- Address-----------------------�� ..Q_X. I .O_�/Q moi' ----•` i� .----- Contractor's Name--------_�J !!__. q��__.. Q_N1P_ ---_f__Lp_ 21 V Phone_.= =--7=--- -7 Installation will serve: ;;Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:.-_ _.Number of bedrooms - __ Number of baths /__----- Lot size __:9C 'f Water Supply: Public,system ElCommunity system E] Private [M Depth to'Water Table :cPQ_ ft. Character of soil to a depth of 3 feet: :Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan Previous Application Made: (If yes,dote---------._--------) No New Construction. Yes U?'No ❑ FHA/VA: Yes ❑ No 1 TYPE OF INSTALLATION AND SPECIFICATIONS: Frn [No septic,,tank-o`r`cesspool permitted if public sewer 1 / Septic T k: Distance from nearest well__, Q___.Distance from foundation___ G'--------Mat r;al_____"G��r�-� --------------- No. of compartments / P Size-_. .1�_ _.Y Liquid depth -- 71 �- _Capac�ty_ �QI pisposal Feld: Distance from nearest well_.: _--_Distance from foundation.l_G__�..-__.Distance to nearest lot line__55_----------- s__ Number of line _________ ---------------------Length of each line__ Q__ *t�_ S/Wid .____ th of trench ""�-------- Type of filter.material------ �_�___ -Depth of filter material______—z___-------Total Jength------/_ ------------------------ -G ; Seepage Pit: Distance to nearest well_:__/!O-[2_..___'_Distance from foundation____,/Q._...__..Distance to nearest lot line-----,5__--/_.._ r Number of pits-____.1-.----------Lining material----�O_c_�---Size: Diameter__tr�- '.�Depfh___.._le____________________ Cesspool: Distance .from nearest. wel!-----------------Distance from❑ foundation________________ Lining material____..._-_______.--------------------- Size: Diameter # ------------------- -----=Depth------------------------------------------------------Liquid Capacity- ----------------------- gals. Privy: Distance from nearest well---------------------------_----------------------Distance from nearest building4 ❑ Distance to nearest lot line------------------ ----------------------------- --------------- --------- ---- ----------- Remodeling and/or repairing (describe):-------------------- ---------------------------------------------------------------------------- -------------------------------------------------------- 1 - = = ------------------------------------------------------------------------------------ t / --------------•-- ----- /fes /�/eP ------ --------- --•- Q/`A -----------------------•---------------------------------------------------•----------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance.with San Joaquin County ordinances, State haws, and rules and regulations of the San Joaquin Local Health District. (Signed) ----- S?•v r lr' ��7P € --------------------------------------------(Owner and/or Contractor) --------------- (Plot plan, showing size of 1 , locatioe of system in relation to wells;.buildings, etc., can be place reverse side). [ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ---�-- B.Q' RATE. �� REVIEWEDBY ----r ---•----------- ------ ---------------- -------------------------------•-- DATE BUILDING PERMIT ISSUED-----------------!------------ --------------------------------------- ---------- DATE Alterations and/or recommendations:° ---- --=--- ------------- -------- - --------- - ---------------------------------------------------•-----------.--------- - FINAL INSPECT ----- {Date---------/""-- - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California f ES 9 REVISED 9-59 3M 3••63 F.P.CO.