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FOR OFFICE US ------- ----------- --- --------------- APPLICATION FOR SANITATION PERMIT Permit No. ._1_ 1.7 ---------------------------------------- ---------------- (Complete in Duplicate) Date Issued --------------- -- ------------------ -- ------------- This Permit Expires 1 Year From Date Issued r Application is hereby made to the San Joaquin Local Heal+h District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. S49. J $^M1 JOB ADDRESS AND LOCATION----- ._ ,;_-- Owners Name__ �� .---- ti Phone --------------------- Address ---------- Address--------•-5.-�.a ew .P {}--------------------------------------------------------- ----------------------------------------- v----------------------------•-_..----------------•....-------•••--•------•••----•-•-••-------------- Contractor's Name----- t?- •-----..�.t._� r T� `1 .. YI..C ----------------------------------1-1- Phone........................... Installation will serve: =Residence [ -Apartment House❑ Commercial ❑ Trailer Court ❑ /Motel ❑ Other ❑ (Number of living units: __f____ Number of bedrooms :,-3_-_ Number of baths _1___- Lot size Water; Supply: Public system ❑ Community system ❑ Private [Depth to Water Table Character of soil to a depth of 3 feet: Sand Gravel Sand Loam Clay Loam Clay� p ❑ ❑ Y ❑ Y ❑ y ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date---------------------) No R!r New Construction: Yes 23--No ❑ FNA/VA: Yes ❑ No ]r t TYPE OF INSTALLATION AND SPECIFICATIONS: i (No septic tank or,cesspool permitted if public sewer is available within 200 feet.) A Septi F.a Distance from nearest well-----------------Distance from foundation____________________Material _____.________- Not of compartments--------•-----------------Size--------------------- -------Liquid depth------------------------ -Capacity ----------------------- Disposal Field: Distance from nearest well-----------------.Distance from foundation---_----------------Distance to nearest lot line.______--_____- ' Number of lines-----------------------------------Length of each line------------------------------Width of french Type of filter ma#erial________________________Depth of filter material-----------------------Total length------------•----:------------•-----_"--•- (� Seepage Pit; Distance to nearest wellj.DD- - Distance ' —Jmz foundation_ - 0_....-•.Dist . ce to nearest lot fine__!:�:v___.._ Number of pits------/-------------Lining material. ___ 4f47'__-Size: Diameter-_3 --------Depth--------- 1 --- ---- Cesspool: Distance from nearest well________________Distance from foundation--------------------Lining material--------.------------- Size: Diameter------------------------------------Dep#h----------------------•----------------------------Li Liquid Capacity q p tY gals. Privy. - Distance from nearest well------_------------------------------------------Distance from nearest building ❑ Distance to nearest lot line_ Remodeling and/or repairing (describe):-______________________ -------------------------------------------------------------------------- ----------•-----------------•-------- ----•-•------•- •-------•----•----- ----------------••-------------------- ------- -r---------------•-----------------------•-----------------•---------------- ------- ---------------------------------------------•--prepared this application and that the work will be--------------------------------------------------------------------•-------------------------------------------- 1 hereb certif that I have done in accordance with San Joaquin County ordinances, State laws, and rules and re ulations of the San Joaquin Local Health District. W (Signed) --•---------•-"--------- -------------------------{Owner and/or Contractor) By:-------------------- ---------------------------------------------I-----------------I--------------- - -----------------..(Tit of 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--- -------------- =1 - DATE _' REVIEWEDBY --=------------------------------- ------------------------------------•---------------------------------------- DATE-----------..---- DIN PERMIT ISSUED---------------------------- ------------ ------------------------ DATE_--------------•- •: Alteratio an or recommendations------------------------ ----------------------------------- - ------ "-- -----•--------------------------------------------------•----•--•-----•----.-------------------- - --y- .- '- --------- -- ----------------------- ----- ---------- FINAL INSPECTION BY:.. _... .__-_. -- -- ------_-- Date---------------- ------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wait Oak Street 124 Sycamore Street 205 West 4Th Street Stockton,California Lodi,California Manteca,California Tracy,California _-$-C-C 6:9 REV16 Ea 6.59 F.P,CO.2M 6.60 rr��