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FOR OFFICE USE: i x� �r --------------------- i4- ----------- APPLICATION FOR SANITATION PERMIT Permit No. ._.F t ----------- ---------- --- ---------------- (Complete in Duplicate) Date Issued ....:-_'-`�_'_...-i This'Pe'rm'it ExN fres 1 Year From Date Issued" I Application-is hereby made to the San Joaquin Local-Health District for a permit toeonstru_ct and install the work herein described. This application is made in compliance with County Ordinance .o. 549 r ' JOB ADDRESS AND LOCATION--------- � -- ----- 1�� '� _ ._. ' --T Owner's Name---------- i - - _ t Q x .. Address..... ----•- ---- i --------- Photi Contractors Na'me---------------------------------- a -,a ---------- Installation will serve: €Residence % Apartment House ❑ Commercial Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I_____ Number of bedrooms __!'Number of baths ---L_. Lot size ___�..--__X___ ___�."�----------- ---`-------._ Water Supply: Public system ❑ Commrunity system ❑ Private ❑ Depth to Water Table-S. ft. Character of soil to a depth of 3 feet: .Sand C] Gravel [I -Sandy Loam ❑ Clay Loam ❑ Clay❑ Adobe[ Hardpan ❑ VT Previous Application Made: (If yes,date______'- ----------) No New Construction; Yes [I No FHA/VA: Yes E] No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or-cesspool permitted if public sewer is available-wi+hin 200 feet.) _ Septic Tank:, T Distance from nearest well_________________Distance from foundation:_-----------.-------Material-----------------------.______________._._____-- E]F ►`�.n1 f No! of compartments--------- -----------------Size--------------------------------Liquid depth--------_i-------------Capacity--:-----•-------------- as Disposal Field: Distance from nearest well------------------Distance-from foundation......--------------Distance to nearest lot line---------------_ Numnber of lines------------------------------=----Lengthh of each line------------------------- -Width of trench----------.-------------------.----- Type of filter material------------------------- of filter material_________-________-._Total length________.-"_______________________ _•- Seepage ,Pit: i Distance to nearest wellAki� _�o_____--Distance rom foundation___��-------Dis#ancq to nearest lot line__`��-" (� Number of pits_____'_____________Lining material______4_ __.Size: Diameter - _..........Depth___ � - r Cesspool: '. Distance from nearest well_________________Distance from foundation.____________'_-__.Lining material____.__.________________--______.. Size: Diameter---------=----------------------------Depth,----------------------------------------------------Liquid Capacity---------------------'------gals . ❑�- i .1 . 1 i ; Privy: t. n Distance from :nearest well___ _________________--- -----`---:---Distance from nearest building_________.______-- a l ❑ Distance to nearest lot line-" ----- -- -- -------------- ------------------------ ---------------------- ---- -------------------------------------------- ----_ --------- ---- _Remodeling and/or repairing (describe): _____ _ ____ ________________________ ________ ________________ ____________ « ______ _ _ __ , + 6 __________________________ i ;- -. -------------- _______________________________________________________________________________________________»_________...._______________________._______-_--______..___________________________.___________________-_____- I hereby certify thfa epared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, nd regulati of the:5an Joaquin Local Health Dis+riot. ;Q ' Owner and or Contractor(Signed) 4 --------- f { / ) � - LSC `_ -- -- _� ---------•----{Title) _ � 1 By:--------------- -----� (Plot plan, showing-size of lot, location of system in relatio to wells, buildings, etc., can be pla on reverse side). , i FOR DEPARTMENT USE ONLY l k APPLICATION ACCEPTED I3Y ------------------=- DATE --� } ------ REVIEWEDBY--------------- ;_1------------ - ---------------------------------------------------------------------------- --•- DATE.._.__...-------------••----------------------------•--' BUILDING PERMIT ISSUED---------•-------`------------------------------- ----=--- DATE 4 _ ---- ., ----_ ------------ --- ----- ----- - -------- ----- ---- ------------------- Alterations and/or rete mendations---------- -----r---------:_._.-�-- ..___. ..'. -------- --- ------- --•- ---•--••--••----------•--....-•----------- _ -� tet• , �--- x_1 � -�`i �� Com. ;,Q �-4 -, ---� � r FINAL INSPECTION"BY-------- -------_-------- Date------------- : �.__ .� ..�- � � AN JOAg 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 r;B-9 RFVIBCD 9.59 F.P.CO.2M 6.60