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FOR OFFICE S o f 1A5 -- �� = 9r • APPLICATION FOR SANITATION PERMIT Permit No '___!. ' 1 Z- ----------= ----------------------------- (Complete in Duplicate] Date Issued -------------------- -------------------------------------- - �I This Permit Expires 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 Count) O�'nance No. 549. JOB ADDfRESS A C�AT10N� ---------------- 702 -�'---------------------------------- ------------------------------------------------------------------------------ a Name �'`�`"�'� -. ::. ------------- --------------------------- -' ------ - --------- Owner's - -Phone-------------------•----• - Address------ 5� -c--------------------------_------ c� Phone----------------------------------- Contractor's Name..---- Installation will serve: Residence 11<4artment House ❑ Commercial [ITrailer Court ElMotel [IOther ❑ Number of living units:,_1----- Number of bedrooms -:A-Number of baths _--.. Lot size -------------------------------- -- Water Supply: Public system �ommuni+y system ❑ Private ❑ Depth to Water Table &q ft. Character of soil to-a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [I Clay Loam ❑ Clay ❑ Adobe Hardpan C]Previous Application Made: (If yes,date---:-_._--_----._._) No gj" New Construction: Yes °�No E] FNA/VA: Yes ❑ No [ J TYPE OF INSTALLATION AND SPECIFICATIONS: -.. (No septic tank`or'cesspool permitted if public sewer is available within 200 feet.) Septic T k: Distance from nearest well-777-------Distance from foundation�---------------.M terlai------------------------------------------------ Se -- ..__---____--.__.__..-__--- ---------/ 3 ocS'}C 9 Liquid de th-----�------------------Capacity..:-l- } No. of compar#mems.---- _ -- -----Size-------------------------- --- - q RMj field: Distance from nearest well...-'^-----.-Distance from foundation-fP—------------Distance-to nearest lot line-`---------_...- Disposal 1 9_0__1--------------------Width of tren z J Number of lines----------------------------------Length of each line - <<-- , Type of filter material___?------ --_---DEPth of filter material__'!---_....i------Total length _------------------------ foundation ---�p------------ r J a . Seepage Pit: Distance to nearest we11-----------------------Distance founda#ion----Ib---------.Distance to nearest lot line - ___.--... 1_l-Q-_L--C-Size: Diameter `3 Depth °�� m +w Number of pits material._---:_ i,. ~- Cesspool: . ..`,��-Distance from nearest well----------------Distance from foundation._-_-.-._--___---..Lining material_---.-.____-_----------------gals. ❑ --------- Liquid Capacity--------------------------- Size: Diameter--------------------------------------- Depth ----------- --� -------------------------- Privy: Distance from nearest.well--------------.__-_._------------------------ Distance from nearest building_-_---____.----_-----_------_-'----------- u Distance to nearest lot li.ne-----:- ----'--------------- Remodeling and/or repairing (describe):------------------- ------•-------------------------- ---------------_----_-----'---f ll --------------------- ------------------------------------------------------:------- ------'------------------- ---------------------------------- = -------- ------•-----•--- t -------------------------------------------•-----•-----•-=------------ ------------- I .hereby certify that I have prepared this appli ation nd that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations the n Joe in Local Health District. (Owner and/ar. Contractor) (Signed):_- 11 . (Tttle--------------------------------------- ---------- -------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 9 F.OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY `� DATE--------/ � f ----------=-------------- ------- -------- - - REVIEWEDBY-----------------------------------------------------.-----:--:---------- ----- DATE ti.<*:. DATE--------------------------------------------------------- BUILDING PERMIT ISSUED-------------------------------- ------------ ------------ Alterations and/or recommendatio s: ------ -------- Y -- -•---------- � --•-----------------•----------- - --------------------------- Fi------ --------------r------------e�_+-------•------•------••------••-----------------I------------------------- --� 3 ----•----� -- ------------------------------------------ i - -------------------------------------------------------------- -- -/--(- ----------------- Date------- �'.5 -------------------------------------- FINAL INSPECTION BY------------ I SAN JOAQUIN LOCAL HEALTH DISTRICT } 1401 E.Haxolton Ave. 300 West oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Mantecd'California Tracy,California ES 9 REVISED 6.59 3M 3•153 F.P.CO.