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FOR OFFICE USE: �f -----------------=-------------------------- Permit No. ....� ---------- --------------------------------------------- '23/ APPLICATION FOR SANITATION PERM � ------------------------- ------------------------------- (Complete in Duplicate) Date Issued ------------....... w This Permit Expires l Year From Date Issue Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein d ed. This application is made in compliance with County Ordinance No. 549. '- JOB ADDRESS AND LOCATION_-(1 !1�? ----- --- ' ``-------4-- � 1 Phone. 7� U..�. - •p Owners Name______1___,p� �--- -- p Y Address-----•----------/---`-�•-•3_2-------- -t------- Cep` r.--•------------------------------------------------------------------------------------•-----_ d --- ------------ Phone-----•----_----------• --------- Contractor's Name---------- .its____________ __•-------------- Installation will serve: Residence C4 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel 0 Other ❑ Number of living units: -�--- Number of bedrooms A. Number of baths ___t'____ Lot size .�-�r _J•�i--• - --• Water Supply: Public system ❑ Community system ❑ Private Depth to Water,Table -W. - ft. of soil to a depth of 3 feet: Sand ❑k Gavel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobejv Hardpan ❑ Previous Application Made: (If yes,date_--------- -----) No X New Construction-. Yes ' No ❑ FHA/VA: Yes ❑ No.* TYPE OF INSTALLATION AND SPECIFICATIONS: oo -(No septic tam cesspool permitted if public sewer{is available within-200 feet) ' -T M17 P Y - Septic Tank: Distance from.nearest well x'1-r�-----Distance rom f�nydation__ _.___ _-__- ater�l___.___________________________________ —No. of compartments_ -- �------------Size--�•---�--6----'!-1.'�iquid depth____-1y---------------Capacity-f��/- m f 4k - ' _-_Distance from foundation___1�--. - Distance to nearest lot line____ --- Disposal Field: j'k Distance from nearest well__s_ __ -- - �i �f r• ; _ Len th of each kine_____ _y-�� f---Width of trench______12-41--1 __ -__� _______________ r- Numberof lines__________ __-------------------- ______ ______ __ g { Type of filter material - t bpth of filter material______ __ _________Total length______1__d. -_______!_.__C Seepa a Pit: Distance to nearest well_-_I C-b d-.... istance from,foundation___ __-------.Distance nearest lot line__ ___.__._ Number of pits----- ------- -----Lining materialrz --- ize: biameter-------, - .-----.Depth------ ------------.--- Cesspool: Distance from nearest well____ .........._Distance from foundation-------------_"-----Lining material-------------------------.----------- ls ❑ Size: Diameter---------- ----------------- ------Depth------------------- -------- Liquid Capacity.. g Privy: Distance from nearest well------------------------- --------------- r•Distance from nearest building-------------_-------------{------------ Distance ❑ to nearest lot line--------- ------------------ - -------------•-- ------ -----------•------••--------------•----------------------••- --- ----- '� ---------------------•-------•-------- ----------------•------� •-----• ,. Remodeling and/or repairing (describe)------------------- --------- •------ - + = _ = --------•---••-------------------------------------- "L --•-----------------•••--------- . _ -----•-------------------- ---------------------------- ---------------------- ---------------------- ----------- --- -- - -- - hereby certify that'I have prepared this application and that the workiwill be done in accordance with San Joaquin ounty I ordinances, State laws, and es and regulations of the:5an Joaquin Local Health District. Signed b� _ GC` r - ------- -------- - ------------------------------ -------(Owner and/orContractor) - -------------• ----------------------(Title)--------------------------- ..(Plot plan, showing sizeoflot,-location-of-system-in-relation.-to wells, buildings,.etc., can-be-placed on--reverse-side).-.r r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY C "--- Tit`------------ -------------- = ---- ' + DATE ar -`` ---•- DATE------------------------------------------------------------ REVIEWEDBY------------------------------------------- - ------------------------ ------------- --------7--- -' , BUILDING PERMIT ISSUED--------------------------------------------------------------------------------------- DATE. - ------------ Alterations and/or recommendations:----------- ---- -------- - k ------------------------------___________________-------------------------------- _ _____________________---__--__-____--- o _________------------- ---------------------_----------------------------------------------------------------------- --------------------_------------_------------------------------------------------ _____________________________ I � t-1— T FINAL INSPECTION BY•. _ - --- ` Date_'---/ ----------- ----- ��-`------�---- -7------------------------•---- FINAL INSPECTION INSPECTION BY��-�-SAN JOAQUIN LOCAL HEALTH DISTRICT 30 South American Street 300 West Oak StraeT 124 Sycamore Street 205 West 91h Street Stockton,California Lodl,Callforn Manteca,California Tracy,California X E6.9 REV16FC 13.59 F.P.CO 2M 6-6P I