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FOR OFFICE USE: -llt. :1 ! _-_--_.-- APPLICATION FOR SANITATION PERMIT Permit No. ...... -- ---------------------------------------------------- (Complete in Duplicate) Date Issued 2/ -.- -- ----------------------_____-------------------__________ 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 County Ordinance No. 549. JOB ADDRESS AND L ATION. Owner's Name...... � r _.. , }------_ ------------------_----------------------------------------------------------------------•--- ----------------------------------- --.._. Phone.......................... -------- -- - - - -------�..1�!��...----,l�el_�.� --- - Address.- +.Y_: /� -------- --------------------------•- y � e ------------`I ------------- ---------------- Phone----------.....---• Contractors Name---=----------- --- --0-/�' ------•.... Installation will serve: Residence1 �partment House [] Commercial ❑ Trailer Court ❑ Motel ❑ Other 0 + Number of living units:_a/__;_ tuber of bedroams__._ZNumber of baths f_.... Lot size .. __ ...r ................................ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table 5D. ft. Character of soil to a depth.of 3 feet: Send ❑ Gravel F] Sa dy Loam [I Clay Loam ❑ Cl;5F dobe�ardpanPrevious Application Made:-"(Jf yes,date........: ..........) No New Constr ction: Yes ❑ No HA/VA: Yes C] No TYPE OF INSTALLATION.:„AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tan Distance from-,nearest well...... -----'.___Distance from foundation....................Material....__........................................... 3f �7� No. of compartments---------•-•--------------Size-----------------•---•----..:.=Liquid depth--------------------------Capacity................... ••--- - r �ro- f ,��_______-•.Distance to nearest lot ir1e._> __...____. Number of lines______________ ____ Distance from foundation_._ __ Disposal Field: Distance f lin nearest well ^`__.- Length of each line_._______________________Width of trench._r _ ----------------- !t : ... r �� - ! yy” Total length..... �f- Type of filter material._.�.�.-_��_4�__Dep+h of filter materlaL._t1________________ ----••:-_------••--�---••-- ��r - Seepage Pit. Distance to nearest well-____._.' _- Distance from Dist-an ce to nearest lot line_________________ Number; of pits..._.______I__-----_-Lining material)^-0_4_!�._______Size: Diameter_.-.,, ____._:..__.Depth____a :�_______________ Cesspbo: Distance from nearest well____.'..______...Distance from foundation__________________.Lining material_._........______.......___.._...... - TDep+ ------------•----------------------------Liquid .Capacity-------------- ------------gals. El Size: Diameter. r ;ii - r. Privy: Distancefrom nearest well,----- ------------------------------------------Distance from nearest building-__.___________---__-_________-----------. I ❑ Distance to nearest lot line-------------------------- --------------------------------------------------------- . r i ----------- Remodeling and/or repairing (describe):----------•--- •------ ' 4 - ' J = ............................:. ---•-- •---•------ ---------- --------•----------_------ .. `aK{•;. z................................................... -- .rt _. i I 1 hereby certify that I have prepared this application and that the work will be done in accordance:with San Joaquin County ordinances, State laws, and rules and re Mations of the San Joaquin Local alth District. ) . - - ---------=--- --=a O =- - -:.. - ----( wner and/or Contractor) Il (Signed)-----------------------------'_ . � -------------•-F - -- I BY: = A `= :_ ------------------(Title).....--------------- ... {Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be Placed on reverse side). FORDEPARTMENT USE ONLY _ I APPLICit-I0N4KCCEPTED'8Y-"- --- -.-- `- ------------------- DATE--------- • ----=------ REVIEWED BY ------------------------------•--------------- -------------------- DATE - - BUILDING PERMIT ISSUED `- ._. DATE ' - -------- - Alteratio and/ r recomme� ation .......................•-•`---___---....__-- --------- ---------------------------------------------- r-------- . -----... ----------------------------------------------------- ---- - - __ ------------------------------------ --- ------ •----------------------- ----------------------------------- ---------- FINAL INSPECTION BY:..------ • -------- = " ------- - �I SAN JOAQUIN`LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 20S West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B-59 ZIA 5.61 ASLAS