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w --------------------- --------- --------- ' APPLICATION FOR SANITATION PERMIT Permit No. .. .. ......... I (Complete in Duplicate) -- - -- -- - -- ---- -- ------------------ This Permit Ex ires 1 Year From Date Issued 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 application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION....�� GZ , Owner's Nam 110 ---- Phone.................................... ----------------------------------------------- Address .. ..... Contractor's Name.--- --- -•-----• -- ___ Phone................................... I Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living.units: j---- mbar of bedrooms .2 -- Number of baths I_.--_ Lot size _��_'�l�f�____ _•__- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ........ ft. Character of sail to a depth of 3 feet: Sand ❑ Gravel ❑ Sa dy Loam ❑ Clay Loam E] Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date--------------------) No New Construction: Yes M"'No ❑ FH-A. /VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) -� Sept T.�n Distance from nearest well_-_-.:---__--._.Distance from foundation--------------------Material-.._-------------............................ :... I No. of compartments-.------•-------- -----Size.----.......--------------=---. q id depth----- --------------------Capacity..............--------- Dis Distance from nearest well. ---._Distance from foundation_. ! Liquid ;�a P ��_-_--....-.Distance to nearest lot line................. Number of lines---------Z-----------------------Length of each line-,/ - - a---------- _.Width of trench--_..-_---"�:914 Type , Type of filter material__ -A.'k--------Depth of filter material...----/8-�---..Total length---------------3Q' - . Seeps 1t: Distance to nearest w ll-�� C j Distant om f ndation--- ....-_.Distance #o nearest lot e............... Number of pits---------------------Lining materia_.:- _- `� --_Size: Diameter____117___-_ -Depth--------... 0 Cesspool: Distance from nearest well----------------Distance from foundation--------_--.--_-__-lining ❑ materia l---.-------_.__------_..._--......Size: Diameter--..----k- Depth. . --------•--------------- ---------Liquid Capacity., .................gls. }l, i Privy: Distance from nearest well----- Distance to nearest lot line. --------_--- -_-----__---_-_-_----_ Distance from nearest building -------- ........ ❑ -----------------------------------------—-------------....... Remodeling and/or repairing (describe)------------------------ ordinances, State laws, and h=ula and r guthislal ap olf a i San Joaquin th w6 Healthlbe - --accordance c _-San ---...------ u .- -` l hereby certify fila+ I have done in accordance wi+h San Joaquin County District. (Signed) -- - -------- ---•-----------------------------------(Owner and/or Contractor) By: --------- --------•--- ... -... {r+le) ... ------- (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-c-- '�.----------- REVIEWEDBY... ----••------- ---- -------------- --------- ---- - DATE------•---••--•-------- ' •--------------------- BUILDING PERMIT ISSUED-----_------------------ ------=-- ------------------------------------1. DATE...--.--- Altera ons and/or recommendations-------------------Y-----------------..-_ ' ------------ l. .o' -.. .. .------- ,----- ---------------------------------- --------------- -------------- . - --------•------------------------- -------- --------------------------- FINAL INSPECTION BY:` ------- -.-_ --------- - Date / ! � -- SA JOAQUIN LOCAL HEALTH DISTRICT 730 South American Street 300 West Oak Syroet 124 Sycamore Strut 205 West'91h Street Stockton,California Lodi,California Mantua,California Tracy,California ES 9 REVISED 8-99 EM 0.61 ATLAS V I