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FOR OFFICE USE: -------------------------------------------I------------- APPLICATION FOR SANITATION PERMIT Permit No. ._... �� ------------------------- -------------------- ---- (Complete in Duplicate) . �u. _ ._ - ._... . ---Date Issued ---------------------------------------------------- -V-- This Permit Ex Cres 1 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. JOB ADDRESS ANQ CATION___. _ _ __ __ - ------------------- Owner's Owner's Name----------- ---- ---- ------ - --- Phone------------------------------------ Address----------------- r ---- ------ ------ •---------- ---------------------- Contractor's Name-------------- - / Phone.. -- ----------- ------------------------------------ -------- Installation will serve: Residence 1.Apartment"House-❑ "Commercial 0 Trailer Court'-Q Motel 1 ❑ Other ❑ Number of living units: __�__- Number of bedrooms_-_ Number of baths _�.__ Lot size A a '_/---___r______________________________ i Water Supply: Public system ❑ Community system Private [] Depth to Water Table J� ff. Character of soil to a depth of 3 feet: Sand 0 Gravel ❑ Sandy Loam ❑ Clay Loam p Clay p Adobe Hardpan ❑ Previous Application Made: (If yes,date--- ----- ---_.) No PRO' New Construction- Yes 9j-'No ❑ FNA/VA: Yes �No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) i Vx Septic Tank: Distance from rnearest well------- Dista a from foundation-_.147-___--__-Maf9ric�L___�__ No. of compartments____ --______________.... --------Liquid depth_-'" Capacity Q_ d-___ ------------ p ty-- Disposal Field: Distance from nearest well_______..___Distance from foundati n____A0..........Distance to nearest lot line__-5=��.. Number of lines____ ________�--._ - --_-. Length of each line___ +r� °� g _�� Width of trench__A9_-0------------------------- 0 of filter material_/�1� epth of filter material---A ___ _______Total length___ ..F i Seep Pit: Distance to nearest well-------r__-.----Distance fr m foyndation___ -----------D' tance --.--___.D•stance to nearest lot line___ __---- Number of pits-__..A..__..___Lining material__ (t`C�___Size: Diameter- '__.____Depth--,----'>�_-___,rl .. Cesspool: Distance from nearest well-------------_---Distance from foundation-_------------------Lining material-___-__-____.-..-__- .._-.__-.__.: ❑ Size: Diameter--------------------------------------Depth--------------------------------------------------._Liquid Capacity----------------------------gals. a Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------..........----_-_- a ❑ Distance to nearest'lot line---------------------------__ ___ --- ' Remodeling and/or repairing (describe):____--- 1 �# -------------•---------•-•---. ------•-•---=--- ----------all---------------------------------------------------- -------------------------------------------------------=----------------•-------------------•------------------- I hereby certify that I have prep4ed this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) - -- ------ -- --------------------- --- --•-----------------------------------------------:j6*m3ttmnjYar Contractor) i By---------------------------------------------------------------------- ---------------------LTitle) ��/��it/ --• ------------------------ (Piot plan, showing size of lot, location of system ' elation to wells, buildings, etc., can be placed on reverse side). " FOR DEPARTMENT.USE ONLY APPLICATION ACCEPTED BY_---- --- - ------ - j c ------------------------ DATE____-K-r-•-- ' � ----------- ----------------------------- REVIEWEDBY------------------------------------------------- -------------------------------------=----------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUEDA-------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ Alterations and/or recommendations:----------------------------"' ^-:--. -...._..w-_--=_= _ , ------------------- •--------- -•--- -----••----...-•-------•---------•------•------------- -----------------------•---------------------------------------------------•--------------------------------------- -------- --------•----------------------------------------------------------------------- 4-13 FINAL INSPECTION-BY:.... -------��----------------------------- _. Qate 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 ES-9 REVIBEC 8-59 r.P.CC.ZM 6.60