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x FOR OFFICE USE:. , -----------------------c ------ --------------------- ~ �• --------------- __._._--------------- --__-.-______.__. APPLICATION FOR SANITATION PERMIT Permit No. ___l.d. ----- ------------------------------------------------ (Complete in Duplicate) / ------------------------------------------ --------------- This Permit Ez fires 1 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 Ordinance No. 549. JOB ADDRESS AND OCATION---------- _ __ _ _ ` -3-�--•----- Owner's •_ `n --------- ----------- --••---- O _------- Phone __�A_J-f Address ................... .......SFe_ ------ P..kt ------------------------------------------------------------ Contractor's Name. = Q_ C Phone-1`i`�� r I Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer CourtMotel E]Other E]Number of living units: __-�__ Number of bedrooms .,-_ Number of baths ._.�__ Lot isize ---------- �___��Q____�______________ +lrFl y 1 Water Supply: Public system ElCommuriity system % 'Private ❑ Depth to Water Table_--- ft. Character of soil to a depth of 3 feet. Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: llf yes, date ______________----- ) NoX New Construction: Yes E]No E]FHA/VA: Yes F1No F1 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 fief.) I ' r 7 g r r q foun�ia`tion -1�.. 1-�l�.Material __C_P (c C-i---o-r'..-------- r Septic Tank: Distance from nearest well__-��Jn: Distance fro ``�� + No_ of compartments---____.�___- r K5 f Size Liquid rdePth .............. Capacity--• Disposal Field: Distance from nearest w I_ 5AQ.Alk!'Distance from foundation__Ib_�f_C1.t__Dista�ce to nearest lot .9 t , ------------- 'P- Number of lines _____________.-.______ Length of each line _____--_ _-__ width of trench .__..-oL____ ial , K r Type of filter material _ klPrQ ___Depth of filter material-___.--.__-__--Totalj length_________ ...IQ:.��___________________ CA Xj ❑ Number of its-------.- ------=Linin material----------^---- --..Size: Diameter ------------------------ Depth --------------------------------- Seepage Pit: Distance to pits well________________g____Distance from -foundation.....__....._..___.Distance to nearest lot line.--__-_-______-__ r Cesspool: Distance from nearest well ----------------- Distance from foundation___ 1. -------------- material ___.__----___-______-__--____________- E ❑ Size: Diameter -------------------------------------- Depth ---------•------------�-�---�-------"-Liquid Capacity ---------------------------- gals. Privy: Distance from nearest well _-_-__;_____________- __-_.__..:_____!__Distancefrom _ . om nearest building_____________________________________._ ❑ . Distance to nearest lot line----�------------------W__ --------�----------------------------•----- -------------------------- �I Remodeling and/or repairing (describe=-----------,-----------------------------------..---------------•--------------......-.---------------------------------- ) . 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 laws, and rules and regulations of the San .Joaquin Local Health District. --------------------------------------------------------._.____ Owner and or Contractor] ned)-------- --- Br--------------------------------------------------------------------------------------- (rfle)------------------------------ --------- -------------------- (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-------------- � - -- ------------------ REVIEWEDBY ------------------------------------------ `------------------------------------------------------------------------ --------- DATE --------- •-------- `----------------- BUILDING PERMIT ISSUED-- - / - T DATE. Alterations and/ recommendations:___�e-%l C--2-.____LC�:__:la_(--__ _ ___ - C.iL'�. --------- -------------- ---------------------------------------- ------ ------------- - -------- - = -------- ---------------14A I -------------- �- 1 - .' - . a -r - - - –--------Yc �,1 ---v----------� ---------------------------- FINAL INSPECTION BY:.- ---------- ---------------- --'------- -- Date---------------•---------------•----------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycam are Street 205 West 91h Street Stockton, California Lodi, California Manteca, California Tracy, California EB -9 REVIBEO B-69 F.F.CO. 2M 6-60