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FOR OFFI SE Q---- APPLICATION FOR'SANITATION PERMIT Permit No. - -- ------- .___. /+�� _ ---------------- -----------------------------------1---- (Complete in Duplicate) - _ "- ssued ---------- ---� _- --_------------------ - ,--------------- .pate I .__. This:Permit Expires 1 Year From Date Issued - / Application is hereby made:�to the San Joaquin Local Healfh District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance N 549. . ,r - : JOB ADDRESS AND OCATI N----- !_?a-----------------• - ill Owner's Name.... - '- '� _ -= .. --- -----. Phon Address -- ----- ----- .�� ..., it Contractor's Name.-- �------ -- .- . -- - -------- '`' Ph/e. .Installation will serve: Residence A artment House ❑ Commercial ❑ TrailerCourtMotel her ❑ k Number of living. units: -/--- Number of bedrooms .-- Number of baths _1---_ Lot siz�a_W_W_A 1-`'---•------------ Water Supply: Public system Community system ❑ Private E] Depth to Water Table, t. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑- Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe `` Hardpan ❑ Previous Application Made:; (If yes,date--------- ----------) NoX New Construction: Yeso No ElFHA/VA: Yes ❑ No-,K TYPE OF INSTALLATION `AND SPECIFICATIONS: k. (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ;I! Septic Tank: Distance from nearest well-----------------Distance from foundation-------------------Material------------------------------------------------- No. oftompartments------------- ------------size__-------------------------Liquid depth---------------- ---------Capacity...-------------------- Disposa FieldDistance from nearest we11087yCDistance from foundation___/d._ _.Distance to nearest lot l je---Field* Number of lines-__-•-- --�/---- --------- Length of each line--------------�Q�--w" 4_„ +ranch-----s _--_.-------_--------- Type of filteXr t _ LDepth of filter material--_.J �( Total length_._._.___ �}-- ------------•---- y1 - - Seeps a Pit: Distance to nearest weli,,-z, ---Distance from ir.Size: da#ion__ Distance to nearest lot line-- ----------- Number of pits.------1------------Lining material -- ----- Diameter__ . -..........Depth- - ��l Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material----------_..-----------._-----_---_. ❑ Size: Diameter-------------- '------------------=--Depth-------------------------------------------- --------Liquid Capacity----------------------------gal s. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------------------------- ❑ Distance to nearest lot line-------------- ------------------ -------------- -------- - j Remodeling and/or repairin ,describe):._ _ __ _______ ___ - ---------- ----- ---------- ` ` ......... ,-------•-------------- -- - - ---------- 4 ------ --------------------------------------- ------------ ----------- 1` ---------------•------------------------------------------------------------ - ---- --- --------------T-:::------ II 1 I h eby ce�,ttfy that I'have prepared t s app'c tion d that the work will be done in accordance with San Joaquin County :ordinances, State laws, and r s d regu ions the Joaquin L al Health District. [Signed) % ---------- Contract ,i- (Owne and/or or) By:--------------- ----1/ - ---- ----------------- tTitleL (Plot-plan,�s o )ot, cation system in relation to wells, buildings, etc., can be placed on raver side). FOR PAT NT USE ONLY f- h DATE APPLICATION ACCEPTED BY ::=` - ------- ----- ------------- !REVIEWED BYN---- --•-- --------------------- - ----------------------------------------=------ DATE BUILDINGPERMIT ISSU'ED.....J ------ ------------------------------------•-----•---•----------------------------- DATE------------------------------------------------------------_ Alterationsand%off recommeni s:-"------------------------------------------- ---------;----------------=•-------------•---•---------------•----------- ••-----------•------------.. F y ------------ T� # 4 - ••-------- ------- ---------•- ------------------------- -------------------- ---- -------------- UUU ------------•------------- ------------------ ---------------------------------- FINAL INSPECTION BY _ ' --------- Date-------- ---- --• ---------- - - ------------------------------- SAN - --- -------------------- A k SAN JOAQUIN LOCAL HEALTH DISTRICT ' 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stocktonr California i� Lodi,California Manteca,California Tracy,California ES-9 REVISED B-59 F.P.CC.ZM