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FOR OFFIC US v ------- - APPLICATIO FO SANITATION PERMIT Permit No. ........................ ----------- ---------------- /------- -- (Complete in Duplicate) 2 -i y- L l --------- - - _ .Date Issued ------------------•-•-- ------------------__------"-_____-______---____-_-:'__. This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Healfh District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. Z0.1. JOB ADDRESS AND LOCATION-- 77j/Z S ` Owner's Nam e.- . --•-•-- Phone----------------------_---------- Address. ------------------------------------------------•---------•-----•------------....._....------...- -- Contractor's Name---- -------- r.....a---------------•------------------------------------------------------------------------- Phone.---••--•-------•--------•----- { Installation will serve: Residence ❑ Apartment House:El Commercial railer Court ❑ Motel ❑ Other 191(LNPQOP— Number of living units: -------- Number of bedrooms ________ Number of baths -------- Lot size ------------------------------------_-_-------------------- Wafer ________ ___________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�Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Ilf yes,date--------------------) No ❑ New Construction: Yes g3-'�No ❑ FHA/VA: Yes ❑ No E&-- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �6 ___ Distance from foundation Material Septic Tank: Distance from nearest well_ Qd-LU_d-°-------------------------•• No. of compartments______ _______ ______S � 2. ---- ize----=�a-��---------Liquid depth----�-�- --------- ______ Disposal Field: Distance from nearest well ° Distance from foundation-Y.0 ..........Distance to nearest lot line.- Number of lines-------- Length of each line-_ ---------------Width of trench.-:4.3-1 Y"____________________ Type of filter material__ _____________ Depth of filter material----/$_----_-__-___Total length____I_-- __ _ __:__---__ _-_____------- Seepage Pit: Distance to nearest well----------------------Distance from foundation------------------..Distance to nearest lot line----------------- El Number of pits-_------------------Lining material-------------------------Size: Diameter------------------------Depth-------------------.-----------.- Cesspool: Distance from nearest well_________________Distance from foundation-------------------.Lining material.___________-__-__-.___----_._______-. , [� Size: Diameter--------------------------------------Depth-------------------•------------------------------Liquid Capacity----------------------------gals. . Privy:. . Distance from nearest well------------------------------------- ------Distance from nearest building------------------------------ Distanceto nearest lot line-------- --------------------------------------•-----------•-------------•------------------------------•---------------------------------- � � p` Remodeling and/or repairing (describe:_--«I�_�L�-- ---- - --•---- -- ------ - ------- -- ------------ •• - / - - - ----'--'-----"' �4'" i►� 1�- = '2!ir+� l �----------------------- ---- --- •------------------------•-••----•--------------------------- ------------- --------------------------------•-•------------------ - -------- --------------------------------------------------•----------------------------------- I,hereby certify-that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, an rules and regulations of the San Joaquin Local Health District: (Signed)--------- ------- fifi ------------------ -----------------•----------------------------- (Owner and/or Contractor 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----.2_:1.t _4--- REVIEWED BY ----- DATE - - -------------------------- BUILDINGPERMIT ISSUED-------------------------------------- -----------------------w-----•--•---------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:----------:------------------------------- --------------------------•--------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:-----. -- --- --Y--------------------- Date------- f �r �------------ --------•------- SAN JOAQUIN LOCAL HEALTH DISTRICT 730 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California REvIaEu B•59 F.P.GO.2M 6.60 1