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FOR OFFICE U E. a`1 "z" �c Permit No. ... ..�__ .,_ APPLICATION FOR .SANITATION PERMIT - --------- ------;� ------ , .? (Complete in Duplicate) Date Issued This Permit Ex fires 1 Year From Date Issued ._ -- - / Application is hereby made to the;5en Joaquin Local Healfh distr.ict�for a permit to construct and install the work herein described. r . This t 385,plication is:made. ncomplincewith Coun.ty"Ordinance No.:5 49,- - - - ircOe 'c - 9 JOB ADDRESS A O N — -�-- y ' -�Owner's Name----- ----- ------------- ---- . - ---------- •----•------------------- Phone. t, Addres -------- --- ----- =_-•--------------- -----------------------• -Phone - -------------------------------- Contractor's NameV... .?4 - -------------•------• ----------•............. Phone P- a-4-I nstallation will serve: Residence [��Apartment House ❑ Commercial,❑ Trailer Court" ❑ Motel ❑ Other ❑ Number of living units: -- Number of bedrooms .c- Number of baths ./-.-Lot size _../_ ©--� d Water Supply: Public system l❑ Community system El Priv ate [Depth to Water Table � t. Character of soil to a depth of 3 feet: 1,Sand ❑ Gravel Or., Sandy Loam ❑ Clay Loam ❑ Clay, Adobe❑ Hardpan j�— Previous Application Made: {cif yes,date-Q -- ---1 No ❑ `N Construction: Yes [INo I�A/VA, Yes [INo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 4 t - � i Tank: Distance from nearest well-----------------Distance from foundation._-_.....___-------Material.........-_------------ ------•----------------- No. of compartments--------------- ----------Size---•-------- ------------Liquid depth-------------- --------Capacity----------------------- os eld: Distance from nearest well ._._---.._.-. Distance from foundation,...._.._...._._..Distance to nearest lot line-------------- - Number of lines------ ----------- ----------------Length of each line---------------------- ---.Width of trench----------------------------------- Type of filter material--------------____---_-Depth of filter material-------......---.'....Total length......-------___-------•--------- ------- r c� �.w Seepage Distance to nearest well_ AO m fo ndation_�F Q_..___.-.. istan5y to nearest lot line./---------- ` s Q_�°_k--.Size: Diameter-- -- . . ------------- Number of pits...._p..............Lining material-/y- - �--�- -�- Cesspool: Distance from nearest well ...............Distance from foundation--------------------Lining material----------.-------_------. ----_------ ❑ Size: Diameter-----------------------------------e Depth----------------- '--------------------------------Liquid Capacity----------------------------gals. ' / 2 _----Distance from nearest building Privy: Distance from nearest well----'--�--`__ -----�=°--�---- ------------ g------------------------------------------ k . ---•--------•-------- ❑ Distance to nearest lot line--7------------------------- . ----- -=----------------------- -------------------- Remodeling and/or repairing {describef:---------------------"------ w ------------------------------------------------------------------------------•------- ---•---•----------•-------- -------------- - -----------------•----------------------------------•---------------------------------------------------------- - - --- --------------•-------•----------------------•-----•--------------------•---------------------- - - --------- ---------- --- I hereby certify that I have prepared this application and'that the work Will"be done in accordance with San Joaquin County 1. ordinances, S e ws, and jul and regulations of the San Joaquin Local Health District. I --- er and/or Contractor) (Signed11:� - --- By= � . ---------------(T fie)---- - -4---------" --- Plot P Ian, showing size of lot, location of system in relation to we uildmgs, etc.. can be placed on reverse side]. 4 FOR DEPARTMENT USE ONLY , I APPLICATION ACCEPTED BY-..-r- `--- - ----c�21------------ --------------------- - DATE . �� . — ' REVIEWED BY------------------------ - DATE = -------- - BUILDING PERMIT ISSUED------------------------------------------------------ ------ DATE Alterations and/or recom endations:.....-. ---••-------------------------- r-=- ---��-- f- -. -.- f ---- -----•----------- I -----------------------------•------------------------•---- --- 1 -----------------"-•----------. ---------- ........... j 4 FINAL INSPECTION BY:..- " --------------------------- Date - 2 �� `SAN JOAQUiN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California CO-9 REYI6EG 8.99 rr P•C O.$M 6.60