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rvK Vrrll.t Uat: .......... ...... ...................... ------ ..... .................................................. APPLICATION FOR SANITATION PERMIT Permit No. ..c .11 d„• ...--- -- - . - .. ........................__..... (Complete in Duplicate) /( }}t� .rE ......................................................... This Permit Expires 1 Year From Date Issued 212 ^D81rIssued q......". 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. .,2.(B Q S ./ �oC . JOB ADDRESS AND ATI�N......... - / zz`�rru�!v - - - -- - ...... - - r - ---.. .x.................. -'-----...--------- Owner's Neme..... -,� �i« ...-- -----` - ......- - Phone.... ------------....Y:r.. .-... _3 ....... .... ----------- Address - Contractor's Name.._-------------•--- .....4a - ... �-----/../' N.. 'CSA.al -G�c ��s...�........ Phone......-•----......--............. Installation will serve: Residence Ament House ❑ Commercial Trailfr Court ❑ Motel ❑ Other ❑Number of living units: Number of bedrooms .yNumber of baths -------- Lot size .... ... ._.c (i ----------- I Water Supply: Public system ❑ Community system ❑ Private [,Depth to Water Table .1-r 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 �1_ New Construction: Yes ❑ No _-FHA/VA: Yes ❑ No KI X TYPE OF INSTALLATION AND SPECIFICATIONS: u / G/ (No septic tank or cesspool permitted if public se er is available within 200 feet.) l z Se tic Tenk: Distance from nearest well...SQ._.Distenf�e fr fou r.-T 10 No. of compartments....�7� Size.4�-. Liquid de 'th._..,:��.... p tyj.� -- Ca aci .. 1_p...... Disposal 'el sfance from nearest well.................Distance from foundation....................Distance to nearest lot line_..._......... n Number of lines.....................4.............Length of each line..............................Width of french.................................... r Type of filter material.........................Depth of filter material.......................Total length........................................ 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...-----.---.................. ._... ❑ Size: Diameter........................ - -------Depth............ -----.......................`......._Liquid Capacity......-------- Privy: Distance from nearest well..---------..............._....................Distance from nearest building-------.................................. ClDistance to nearest lot line..........................................a--------------...._........_........—.................................................... Remod nd/o ret describe):...... ... .. ....... _.. .. '....... .....................................-------- ----------------......................--------......... ..........-------------- -- . ----.------------------•--'--..............---......... I hereby certify that I have prepared this application and the the work will be done in accordance with San Joaquin County ordinances, State I s, ani ules and re ulations of the San ' Joaquin Loca/�eal+h District. (Signed).. . ----. ----------------------------------------- . Owner and/or Contractor .................. .................... By:---------------•--•----•--------..........___....------. � ---------�"---------------------------------------.........(Tifle)...------...........------...........---................... (Plot plan, showing size of lot, location of system in relafion to wells, buildings, eta, can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY..........................................- ..... - . ..............y . DATE...... - f----- .................. REVIEWEDBY.............----- ---------......-------...----------....... DATE'-__/........ c..12..�....__.......... BUILDINGPERMIT ISSUED----- -......----..................... .................._............ ... '�. . ...... DATE..----.................................... ............. Alterations and/or recommendationsc......................................................._..............................._......................................4........................... -- --- -- --- ..........................................-......---- -_._.______._...•••••••--------------...............................•........................-------.-•- ..................................................._.............................................................._......._............-•-•• - ---._......_.._...._................. --------......... - .............. ... .... ...... - - ffAA- - - .......... --- GG,,� �—y� FINAL INSPECTION BY:......... ..... � `�` '.r... Data--_---.....+1......:� � SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 1.Massif"Ave. 300 Wort Oak Sties? 124 Sycamore Street 205 Wart 9th Street Stockton, California Lodi,California Manteca,California Tracy,California F.P.Ca.