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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. �2,,V Z. --- - - -- �3 � 4 -------- --- - -------- -- --------------- Complete in Duplicate) —� — 7 ----------------- _ _____ This Permit Expires 1 Year From Date Issued 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 54 9. JOB ADDRESS AN CATI N =---- --- --/ --------- - ------ � S_4:aw Owner's Name-------- ------- ----------- -------------------- Phone-4- / �3YO Address--------_-------------�.r . C.v ----- - ------�-7 ------------- — ----------M ------------------------------------ Contractor s Name----------- -- .�. - Phone.. fP -- Installation will serve: Residence K Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ -Other E3Number of living units: -1------ Number of bedrooms _t--- Number of baths 1------ Lot size .- .-1- -------------------- Water Supply: Public system % Community system ❑ Private ❑ Depth to Water Table"-o-- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [A Hardpan ❑ Previous Application Made: {If yes;date--------------------I No New Construction; Yes ❑ No 0. FHA/VA: Yes ❑ No j TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation-------------------Material_._-_--.__-_....___-_._-----_-_--------------_-. y uS'{l No. of compartments--------------------------Size-__-------------------------Liquid depth--------------------------Capacity------------- -- Disposal Field: Distance from nearest well.&AM-Distance from foundation_jf.......... Distance to nearest lot line_-S___--___-- Number of lines. �1-- Length of each line__ -- Width of french----� _!f �p � Q ---- Type of filter materiaL_�L�t ------Depth of filter material----------1_g�{_Total length---.---�P----_-___--------------- �►, :° r \ Seepage Pit: Distance to nearest well__ QW-67__-Distance rom f undation-_,�4_ ._._.Distance to nearest lot ime._�Q Number of its_ - - « t p' ��f_ ___Lining material_ --Size: Diameter.___�.�_ ._.f�-Depth_.__`�._�`__________________ Cesspool: Distance from nearest well-----------------Distance from foundation...------------.___.Lining material-------------------.-----_-._-.------- ❑ Size: Diameter------------------ -------------- ----Depth--------------------------------- ------------------Liquid Capacity- ------------------------gals. Privy: Distance from nearest well---------------------------------.------------.--Distance from nearest building----------------------------------.___---- ❑ Distance to nearest lot line------------ ----r---------------------------------------------------------------a---------------------------------------------------- Remodeling and/or repairing (describe):----- - ------• --------------------------------------------------------------------------------------------------------------------------- - - - --------- -------------------------------------------- ----- - I hereby certify that I hav repared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and le and regQatio f the San Joaquin Local Health District. Si ned ------------Owner and/or Contractorl (Signed) T1tle By:--------------- ---- --- ( ) (Plot plan, showing size of loft, location of system in relation o wells, buildings, etc., can be place n reverse side). i F R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- DATE------/=/f7-4 - ----------- ----------------- ------------- REVII WE BY --- ----- --- ---- --------------------------- ------------------------------ DATE--------------------------------------------------------- EVIEWED PERMITISSUED----------- ------------------------------------------------------------ ---------------------------- DATE.---------------- ' Alterations and/or recommendations----------- ---------------------------- - -----------_--------------------------------------------------------- --------•------------------------------ ----------------------------------------------------------------- -77Z —--------f .� f / P ------------------------------------------------.._---_..._---_ FINAL INSPECTION BY:. ---- . -- ---- ----- ----------- Date--------- Y= �---------------------- ---------------- QUIN LOCAL HEALTH DISTRICT 3 1601 E.Haxollon Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stecklon,California Lodi,California Manteca,California Tracy,California I