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FOR OF ICE USE: ------------------------------------- -•---- .......................... APPLICATION FOR SANITATION PERMIT Permit No. ......................................................•.- (Complete in Duplicate) i' Date Issued ---�1 X... ,6 ------------------------------------ ----------------- This Permit Expires 1 Year From Daae Issued Application is hereby made to the San Joaquin Local Health District for a perms to construct and install the work herein descrbed. This application is made in compliance with County Ordinance No. 549. &37.5'A) -, it JOB ADDRESS AW LOCATION_) 'krss".-�.-t-r -s +n1.9,esLrfr _ .. - --- '�-=-" r_r " Q+a-...-_-19If`11w-yo Owns r`s Name._ . . _.. 6 -- - ....-•...-.-•.••---•-•---•..... ........, ..,..............-----..-�...•..:--......- ---•--.•-- Phone...................................... Address------------- ....... _ ._ Contractor's Name r •. .. d a ------------------------------------------------------- phone........................---------- Installation will serve- 'Residence Apartment House ❑ /Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ .. ' .., of bedrooms _Y.. Number o aths -..._ Lot size _- - :----. ____________ Number of�,living units: .. .. Number Water Supply: Public system ❑ Community system ❑ .Private .�Dethf a#er Table ........ ft. Character of soil to a depth of 3 feet: : Sand ❑ Gravel'E] Sandy Loam Clay Loam ❑ Clay ❑ Adobe I] Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPEOFINSTALEATION_AND SPECIFICATIONS: �,,... a(No sepfic"�fartk or cesspool permitted if public sewer is available within 200 feet.) a / Septie-• nk: Distance from nearest well.__5'd--- Distance from foundation-.'70-_-r_-.....Material-_-.-. .....................: No. of compartments_..-." .............size-4 l b` y��IC!.1•J.Liquid depth.__ -.�...............Capacity.( ap.- t � Disposa le1d. Distance from nearest well-_.YA..--....Distance from foundation- I'V!........Distance to nearest�t�ine -------------- 0 F Number of lines-------- ----------------------Length of each line........ ..P..l.__.......Width of trench.--..__.._- Type of filter m64erial...__.5?.&---___Depth of filter material...... Total length.........j.F_.0.................... ,� p 1g E + t See a e Pi+: Distance to nearest well..........._._.._._..Distance from foundation....................Distance to nearest lot fine................ ❑ Number of pits..-------=-----------Lining material...--_----------t-----Size! Diameter-----------------------Depth—Z- `C Cesspool: Distance from nearest well.-__..._-:r.......Distance from foundation-------------------lining material_--------------------------......... d ! ❑ Size: Diameter..............................-"-.-_-Depth.......•-------------------------------------------Liquid Capacity•-----.-----._...._....._..gals. Privy Distance from nearest well.................................................Distance from nearest building-----------..-.--_--..__.-_--:........ ❑ Distance to nearest lot line-----------------------------_---•-----------------------------------...-......----------._.-....--••-------------------•---------------- Remodeling and/or'repairing (dascribe�: �`��-r `'•• ' ' .f•-.............--•--•.............................................................. .........................................................•--...................._-.............................---.....-----._............-....-•----..--..-....-•-•--------.........-•---------..--.----------------•-------- I hereby certify fhat I have prepared this application and that fhe work will be done in accordance with San Joaquin County ordinances, Sfafe.laws. and rules and regulations of the San Joaquin Local Health District. (signed)---------------------- ------------------------- . . .................................-.................................................... r and/or Contractor) By ----; (Title)....... .. . _ ....------------------......--------- -------- .. (Plot plan. showing sire of lot, location of system in relation to wells, buildings, etc., can be placed tm reverse.side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_... - tr.-.-.---•--•-•........:................... ......................... DATE....2.7_.L1.g. �.. REVIEWEDBY.....-------------------------------------------.................................•---••---•------•------------_-............. DATE-•-----------------•-............ :.. BUILDINGPERMIT ISSUED....................•-----................---................,...............----.........._-••----- DATE----------------------....... Alterations and/or recommendations:.............................................................•---........................................... - ..............................:...............................................................•...................•...................................................................................................-------- f -----------------------------------------=...... ---------------------------------------------------• ...........................................-........................................................... I •: FINAL INSPECTION BY:...... 2,r?? ....- Date.. ..L. ."1.. ........ f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 144 Sycamore Street 205 West 4th street y Stockton,Callfernla Lodi,California Manteca,Colifornia Tracy,California I CS 9 REVMEP a-59 3M 3-•63 F.P.CQ. ,