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FOR 01Fr10E USE: ------------- -------- --------------- ------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ...... .__. (Complete in Duplicate) W411 19 `� �..--rt "Y Date Issued -•---•-•--_-._----__�?� This Permit Ex fres 1 Year From 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 applic tion is n cpr� liance ith County_(O�rdj mance49 1 OB ADDRESS AN OCATIO�N_-- �< ----1 ---------------•-•------- ---lJ -� ---- h . --- --- Cki :! (� Owner's Nam - • --X47 ----- ft-jA ---------•- -----••---------------------- - --•--- Phone----- •------� - .r _ Address-----•-- 0- Contractors Name. '..._. •-------------------- Phone.. K' Installationywill serve: Residence [Apartment House E] Commercial ❑ Trailer Court ❑fMote) ❑ Other i Number of living units: ._----- Number of bedrooms __��Iumber f baths ___1___ Lot size __- 2I 3>---- �_-�7________________________ Water Supply: Public system ❑ Community system ❑ Private (!Depth to Water Table __Lt_ ft. Character of soil to a depth of 3 feet: SandGravel ❑ Sandy Loam [✓Clay Loam�VNo lay [:] Adobe❑ Hardpan C]I Previous Application Made: (If yes,date____ _ O'l�I.QS.-Ho ❑ New Construction: Yes ❑ FHA/VA: Yes ❑ No F< TYPE OF INSTALLATION AND SPECIFICATIONS: [No.septic tank or cesspool permitted if public power is available within 200 feet.) I 6 Septic Tank: Distance from nearest welL.___�;b---..Distance from foundation___.: Ma erial____ _._ r____._�r ' No. of compartments------- Size___ ___ .Liquid depth___ _____________Capacity_--__ f Dispos Field: Distance from nearest well-___.,____.Distance from foundation _____(I--------Distance to nearest lot line.....y---, t� Number of lines---------- Length of each line__-_.___ Width oftrench_____�r_______ _ _____+ t -- t Type of filter material---- _ ___ epth of filter material-___-_�_.�_________-Total length_.____�__� _---------------------- Seepage ___________________ - Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line----------------- F-11 Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Dept h-----------------.---.-_--------- Cesspool: Distance from nearest well-----------------Distance from foundation---------------------Lining material------------------------------------- El Size: Diameter------ -------------------------------Depth---- -----------•--------------------- -------------Liquid Capacity-------••------------•----..gals. F Privy: Distance from nearest well-_______________________________________________Distance from nearest building 9 ------------------ ❑ �� Distance to nearest lot line--------------------------------------- Remodeling _________________________Remodeling and/or repairing (describe):-------- ----------------------------------------------------------------------------------____-----------------------------•-------•----•----------- Td ----------------•-•'---------- -----------------••---••-------------••--••--------------------------------------------------------•---------------------- ---------•-----------------------------------------------•---- ---------- �- -• -------------------•-•---------------•------------•--------•---------------------=-------------------------------------------------•--•--- --------------•------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances,;State ws, and rules and regulatio s of thZ oaquin Local Health District, i (Signed)- ` - ------- --- ----•------------------------------------------------------------- -Ow and/or Contractor) j By:.-'.!------------------------- ------------------------------------------ ------------------•-------------------------------------(Title)---------------------- ------------------------ ------ (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----- - ------- -REVIEW=DBY- ----- --------- ------------•-•-------------- DATE------------1i------r----------s-,I- -- BUILDINGPERMIT ISSUED---------------------------------------------------------------•------------------ -------------- DATE------ Alterations Iand/or recommendations---------------- ------------------------------------------•----------------------.-----------••-•-----•----..----------•-•----•---•-------•------------------- I -------•-------------------------------------------•-----------------------------------------------------------------------------------•----•---------------•----•-----------•-----------••------•--------••-....------•---- ii - --------------------li------------------------------------- .•• --------------------------- --------------•------•----------------- ------------------------------------ -------------- ---------••------------- -----•-------------=I,-------------------------- •--------------------------------------------------------- ----------------- ------------ FINAL INSPECTION BY:_--_.....__Z /.- ^�:.- 6 t.� - f� fit- Date / --------•-----------•--- ' t r SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street ,a Stockton,California Lodi,California Manteca,California Tracy,California E6.9 REVISED 9.59 r.P,EEI,aM 6.60 }