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J SE:..FOR OFFICE USE- ... .. ............. I ......... ................I......... . ............ `/ r APPLICATION FOR SANITATION PERMIT Permit No...l.tir...,- .................................................... (Complete in Duplicate) jl�i f Date Issued .......-Il...... .................... ................................ ... This Permit Expires 1 Year From Date Issued � f 7— O Ff�.—S/ 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. jaM JOS ADDRESS;AND OCATfON C/ rel-ts�,G-ri .... lt-+Cr ./.t..„�,��. , ,..R <Q- ..k'. -_' ► 1,rE 4' ....... Get �J f� Owner's Nam y ?. t.Lc i+P,.�`.1ie...... .._?�..."—&-b^;.._..�n.a................................. Phone .............. . .--••----..... , ,ry + Addressi �_.. .. �7. .................. _.... :. - �.Q .. ............. •................ Contractor's Name..........'.. �.-!-'�4rs�?-�'.l.�l...•..!_.a. .`-t'.? �...._.......................'................ Phone.......,.,,..._........... ....../ .._... Installation will serve: Residence ❑ Apartment House ❑ Commercial [6railer Court ❑ Motel ❑ Other ❑ Number of living•units:. Number of bedrooms =. Number of baths . Lot size ...... ..................... Water Supply: Public system ❑ Community system ❑ Private [Depth to Water Table ....._.. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [ivj Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made, (If yes, date........ } No ❑ New Construction: Yes ❑ No ❑ PHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: . (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 1 Septic Tank: Distance from nearest well ................. Distance from foundation................. Material .................. .............................. No. of compartments ................. ..Size..................... .......Liquid de th Capacity '� Disposal geld: Distance from nearest well... 0< Distance from foundation,. /.._.:.......Distance to nearest lot line.........i........ .%N Dull Number of lines ........ __.......� Length of each line'..t..._'...p.....Widtli iif trench..,:. ................. •�� Type of filter material../: r......._Depth of filter material ......... ........Total length- Ko!?_ ............... ...... L j Sa�r#; Distaisce`fa�Veaaest well ...... %.:...:..._.-Distance from found ation....1:.0......... Diltanc/e toynearest to �no... �f- .... ... �] Number of pr /... _... Lining material____. ..Size. ' �....1-� Depth_....:......_�. Cesspool: Distance from nearest well ..... ..........Distance from foundatiori ..._ �_�..:-`::...Liningtirnaterial......................._...�-....... C Size: Diameter ..................... -"'T` . ❑ Depth ............................'........;.._........iquid'Capacity...._........ ..... gals. Privy: Distance from nearest we'I............ ..............................Distance from `eai•-est building ....................... .I...��...... ❑ Distance to nearest lot line..............: ....................... .... ....... -........... ................ ............_.._........... ............::.......... Remodeling and/or repairing (doscribe):........ .. .12!lyia.�?.... k. ti ti -• .............I...............-- ......... ..................... ................................. ................ ..........._............_•............. ... ................. :.-....-------........_........ I here6y certify that I have prepared this application pnd Ahai the work will be done in accordance wifh San Joaquin Count ordinances, State laws, and rules and regulations of the San -Joaquin Local Health District. (Signed) ..............: -- .......... . ....... and/or Contractor) _ t `T' Title .... BY: ......... _._..r..._,...... �; { } ...................I—..............., `L� ... (Plot plan, showing sire of lot, location o Sy s em In• lafion to wells, buildings, etc., can be placed on reverse side), FOR DEPARTMENT USE ONLY --�- ............................. DATE.. ------. ..:�- APPLICATION ACCEPTED BY........,�: �..7..•................................. ..........__......_....... REVIEWED BY ... ........................................ DATE .........................._................ i ... ......... . BUILDING PERMIT ISSUED ............................. ..................... . ..... DATE................... Alterations and/or recommeynoofi ns:/..................r..7................. ..................... .... ........................................ .......... I.............. ................. •n."31.............. /.: �G,?� ....C1 ��.s............ ........r lam........................... ....................................... ......................... ... . ....................--..........................................---..........:....................................I......._.................. ... .......... ................... ............................................................................................................................................................................ .................................. ..... FINAL INSPECTION BY: ......... .1 Date. ...... ........... . SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 Wost 91h Strool'i Stockton, California Lodi, California Manteca, California Tracy, California • CS 9 RFVISGD B•99 3fA 3-'63 F.P.CC.