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. FOS OFFICE USE: " r APPLICATION FOR SANITATION PERMIT Permit No. .l..Y�_ ...� - - -__I----"----------------- (Complete p - ----, f-- ----- - - Ctin Duplicate) Date 'Issued - ------ --- !I-._____..--"____._-_ This Permit Expires 1 Year From Date Issued . Application'is'h e -y ade to the Sa Joaquin Local Health District.for�permitµto.constru t and ins#all the work herein"de`scribed. This application is made in com liance,�with Cbunty-Ordinance•No.u549.-?I P JOB ADDRESS AND LOCA_TIOitI-------2A -I � ---�- ' �� `� � � r ' i P [ Owner's Name."-'!_ --- Phone-- •a ` k_�f #tT cis# fr ,S Yr\ -- -- - ------ ........ --------------_ Address I - --------------------------------------- Contractor's Name .r h�- = L� ©N 1 � .------ •------• Phone..... :i �L _ Ie, c ` ' 41 rve: Residence "Apartment Housel❑ °Commercial ❑ Trailer Court ❑ Motel ❑ Other,❑ Number of baths -_' ` Lot sue --- 7 -------- --�•�Q ---------------------" Installation�wtil�s _ Number of;{iving units: __ Number of bedrooms Water Supply: _,Public system ❑ Community .system ❑ Private Z Depth to Water Table,. _,ffi.,, Character of soils to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ 'lay�Lo T'i❑ Clay ❑ Adobe Q Hardpan ❑ i Nl�,J Previous Application Made: [If yes,date________ ___________a -No � New Construction. Yes ❑ No FNA/VA: Yes ❑ No 1 TYPE OF INSTALLATION AND SPECIFICATIONS: I No septic tank or cesspool-per if-public sewer is.available'within 200 feet.} I P ,, oo P P Septic Tank: Ii Distance from nearest well_'_____ --___Distance from foundation_ _________________Material__`_____----_-._ ----------------- ------------ ❑ No of.compartryients----- --- --- $ize --------Liquid depth-N-------- Capacity i Disposal Fields Distance from"nearest well-%------------------Distance from foundation--------------------Distance to nearest loft line----------------- I ❑ Number of lines------------------------------------Length of each line------------------------------Width of trench.--------------------------------- T off ilter material-------------------------Depth of filter material----.------------` ,--Total.aengfh=_-------7�- ----------------- ---•-- Seepage Pit: . Distance to nearest,well__NQ_f`1- _____Distance from foundation---_10'_1.......Distance to nearest lot {ane"-"._ _______._ � t a � ll Number of pits._._'!.__,-_____:Lining material__ _ ---Size: Diameter_______ ? !bepth-_-_...__ 47--1___"______ Cesspool- i Distance from nearest-well--------------- Distance from foundation._. ---------[__Lining material- ---------------------------------- Cesspool: ___.____-- -"_______.. ' Liquid Capacity ❑ Size: Diameter =, Depth q P Y ... - gals. O }8 Distance from.nearest buildin Privy: Distance from nearest well------------------------------ "------- Y 9 ---------------- ' ` ❑ " Distance to nearest,lot line- -- --------------- - -------- El --- I Remodeling and/6r.—repairing;repairing {describe):----- - t ----------------------------- ` i s' ----------- ------------------------------------------------------- ---- -------------------------= ------------------- aI �� ------------------------•---------------------------------------- - 1 ---------------------------------•-------------------------------------=-------------------------- ----- -------------"------------------------------------------------ 9 9 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 re ulations of the_San Joa uin Local Health District. (Signed) 1D ------ . ----------------- CA. ------ --------Owner and/or Contractor) BY' + '. in size of lo---location o system In relation to wet (Title}""______________-".__.___-"_:--:-- �. ---------------- +: - --.__..-}_ ''°-' -`------------- -------•--=------------- Plot len shav%_ Is, buildings, etc., can be,rplaced.on.reverse,side}.------- side)..,_ , 1 FOR DEPARTMENT USE ONLY q APPLICATiON�ACCEPTED BY Grp'-`- ----- DATE -�� { ��. -� REVIEWED BY�------------------------------------- ._. = DATE---- ---- ----- t rs:----•F- -r-- ' �----- -r-- -�F.-,- ---•---� =�-- DATE------------------.------------ ----------------.-.-v---------- � BUILDIN�G"7�PERM,-I-T---�ISSUED_ -------•----'•'•-•-fi---r----- -------------------------------. - ........ ----- ------ � � ........ _ -- . Altera+ions and/or recommendation ----------- - ------------ ----------------------�------------- ------------------- -------- ---------------------------- ----- -----"""- - -•--------- � ----•-------"---------- -"---" - ---------------•--------- ------•---l , a , ------------------------- ---------------- ------------------ �------------- .I -------------- -- --------------------------------•----------- --- �.. ... - 1 FINAL INSPECTION BY...- -- !a�f� -•---- Date - j AN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Maxelton Ave. 0 West Oak Street 124 Sycamore Street 205 West 9th Street i Lodi,California Manteca,California Tracy,California Stockton,California E5 9 REVISED 8-59 3M 3•'63 F.P.0 17. i�I