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FOR OFFICE USE: APPLICATION FOR FOR SANITATION PERMIT Permit No. 6 ---------- ------ (Complete in Duplicate) 2 Date Issued .__. _________ __.-__ ;This Permit Expires I'Year From 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 p� JOB ADDRESS AND OCATIWrlf �. 4lrf ,/ R Owner's Name----- v '- -----••------------------------------•------------------- o- Phone------------------------ Address _._.. Address---------- � --------- Contractor's Name---------- -- ----•------------------------------------•--------------------•---------•-•--•-•-----•-- Phone----------------------------------- Installation will serve: Residence 'Apartment House'❑ Commercial ❑ Trailer Court [I Motel ❑ Other ❑ i Number of living units: _ ___ Number of bedrooms __ Number of baths _/__- Lot size _X_/A��_______________________ _________ Water'Supply: Public system ❑ Community system Private E] Depth to Water Table AAP €t. Character of soil to a depth of 3 feet: 'Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 130'sardpan ❑ I Previous Application Made: (If yes,date__.--------,-------- No New Construction: Yes gjol�o ❑ FHA/VA: Yes &?' No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (Na septic tank or cesspool permitted if public sewer is available within 200 feet.) I Septic Tank: Distance from nearest wall__-- Dist ai� from foundation--- -------Matef ____ _._-___. No. of compartments___:__ ______________Size_ __ ___#0___Liquid•depth___�___X.__:___:._____Capacity__dQ___--.__- -- 9 �r� ,/� ' �, Disposal Field: Nlumbee ofolines earest well___:_ ____.__.Distance from-foundation__/�____.__._.Distance to nearest lot�ine...i�'..___.__. �_- Length of each line_____ __ ____ _ _____ Width of french,--,g,- Type of filter mater:iaZ _ De th of filter material_ __ p Total length /W;P. Seepage Jt: Distance to nearest well-----= '"t--------DistancAe;; a#ion__..�(�..�_..Distance to nearest lot line__.hf� �. Number of its_____ _ _Linin material_ Size: :Diameter_'_,. . ��_'`__-Depth__- �P g Cesspool: Distance from Weare t well_______---------Distance from foundation------------------- Lining material--------.---___---:--_-._.-__.-_.___. ❑ Size: Diameter--------------------.--------- -----.Depth---------------------------------------------- ----Liquid Capacity_--------------------------gals. Privy: Distance from nearest well________________ __ _Distance from nearest building Distance to nearest lot line__-_--__'.'__-___----- ----------------------- --•------------ f Remodeling and/or repairing [describe) 1 -------------------------••----------------••-------- O ..............................--------.-------------.-.____-»_____--.____._.--------.---_--------------.--- ___________.__-._.____.._ -_.__...-____.____..-__.______-__.._______._..___.___.__.___..__________________-_____ --------- ----------------------------------------------------------_______._.._._._.._______________________.______________..______._________________._.___..____________________________..____....________-_..._.-.-__.___.__ ________________________--__________--__._____________________-______-___________________•__________________________________._______________.____________________.___-.-___--_-______.-_._____________________________.__.___ 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, and les and regulations of the San Joaquin Local Health District: Signed( ) ------------------ =" r Contract Bye = -------------------- (Plot _ - - irtle): - ----------------------- - - (Plot plan, showing size:of lot, location of system in tion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY _ APPLICATION ACCEPTED BY -------------------------- DATE------ ---�=�-^--- -- r REVIEWED BY-----------•-- -----•----------•-----------------=---------------------- ------*------------------------------------ DATE- PERMIT ISSUED-----•---------------------• ------- ------- -• •-- -----------•--- DATE-------------------------------------------------------------- Alterations and/or recommendations:_____________________._____-_._ ------------------------------------------------ --•-------•-----•------------------------- --�------- --------- . _ .......... ------------------------ FINAL INSPECTION BY:. �� -( �� >~ =i. �.. -Date. - ----•-•-------- -------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT' ' 130 South American Street ; 300 West Oak Street 114 Sycamore Street 205 West 91h Street Stacktonr California Lodi,California Manteca,California Tracy,California d EU-9 REVIOEO a-59 r.P.00.2M 6.60