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r �f ------ APPLICATION FOR SANITATION PERMIT Permit No. SR- ,- (Complete in Duplicate) t - ----- ------------------- ------- This Permit E cipires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Heal+h 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 AN�CATION_______ �--__ - -------------------------------------------- wner's Name--------- __Q_,� _• �� - p l -----•----------------------------- Phone Address C1- �4- - ---•-•- ! Contractor's --------------Name-----1 Phone. -- - ---------- ------------------------------------------------------------nstallation will serve: Residencepartment House.[] Commercial { � ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:, __�__-�_ ben cf bedrooms___ Water Supply: Public system- Communitysystem f y ❑ ' Private ® Depth to Water Table,,� 'ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel [] Sandy Loam ❑ Clay Loam �';{ Cla TYPE OF INSTALLATION.: 4 y ❑ Adobe rdpan ❑ Previous ApplicationMade: AND No New Construction: Yes 10 ❑ FHA/VA: Yes ❑ No �- ND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T Distance from nearest :' °' Distance from foundation d -------- Pial --{5�, - No. of com artments_.__-_ _ C,, �p E�1__--:---Size_ frt�- Liquid,d �*].�--- ----Capacity------ �--- Disposal Field: Distance' from nearest well_._--�-----Distance from foundation__ / Distance to nearest lot line C6 ❑� Number•'of lines----------F -- Length ' each line__\__ f /, e -T--- - g -- - Width of trench._ /- Type of'filter material_ _ _- ij ------------ Ar / Depth of filter materia! Total length-------- �- --------------------- ,Distance + Seepage to nearest ell______._________- Dis#ance r foundation___ -�_ 1 __,__. _.Distance to nearest lot lie - Number of pits----- ---------- _Lining maternal___1-,4-6-OP-Size: piarrieter__ ! f�� r Depth -------- Cesspoof: ' Distance Jrom nearest well________________Distance from foundation.---- -------- Lining lining material_____.-____-_-___-,_ -. Size: Diameter_ Depth --------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well___-_______________-------------------_.__-__.Distance from nearest building-. z to nearest lot line------ -------- Remodeling and/or,repairing (describe):__ � - -------- lhereby certify that I have prepared this application and the+ the work will be done in accordance with San Joaquin County 1 ordinances, State s and rules an regulations of the San Joaquin Local Health District. (Signed)----- � - -- -------------------- ------ By:-------------------- � when an Contractor) and/or C or) (Title)--.0- �---- --------------------------------------- (Plot plan, showing s' of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 8Y----_-.____-C -- ------- ------ DATE--------. 5' - ----------------------------------------------------REVIEWED BY ----------------- DATE PERMIT ISSUED__.--=---- ------- DATE---- ------------=------ --------------- ---------•------ -------- -----------------------------------------------`----------------------- Al+erations nd or recommendations _---- ----- - --- - � DATE____-.:_'____-____-__-_____-___-,___-.-_ _--__----__-___ -� - _ ----------- --------------------------- - -- - ---- - - - --------------- =--------- - -------------------- -------- ------ --------------------------------- --- ---- --------------------------- -------------------- FINAL INSPECTION BY-------- ------- _ -------------- Date_ S - -----(---- ------ ..... ----------------------------- SAN ___SAN JOAQUIN LOCAL HEALTH D15TRICT 1601 E.Haselton Are- 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California ManteLa,California Tracy,California w