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FOR OFFICE USE: w ---------- - --- APPLICATION FOR SANITATION PERMIT Permit No. ,•.•- -------------------------------------- -----_---.--- (Complete in Duplicate) Date Issued ___" ..-_- This Permit Expires 1 Year From Date issued r 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 wit County Ordinance No. 549. �OB ADDRESS AN LCATION.___" -_ -----,,,� _ ------ - - - r------- 0 Owner's Na i -- - ----- --- - ----- -------- Address x� ,,.?.4--- A Contractor's Name •r .rt. ---- -•--- --- - ---•- Phone Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑w Motel ❑ ' Otherp`�-+' Number of living units: ._.----- Number of bedrooms -------- Number baths.3-_ Lot'size - -------------------1--------.__----__-----_------""-_.-.; Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table ----- ft. r i Cla &Adobe [Hardpan M. Character of soil to a depth of 3 feet: Sand E] Gravel ElSandy loam ❑ Clay Loam ❑ y ❑ �f Previous Application Made: (If yes,date------------........) No ❑ New Construction: Yes ❑� No ❑ FHA/VA: Yes ❑ No, �'(} TYPE OF INSTALLATION AND SPECIFICATIONS: apo f Ch (No septic tank or cesspool permitted if public sew"a*e within 200 feet.) Sep#ic ank: Distance from nearest well_`I_Distance from found ion-----1 Q--.------.Material-------------- No. of compartments--___ _______________Sizer __ ---- - Liquid depth_----- Capacity".AAC�Q - --------- Disposal Id: Distance from nearest 2well__aSA0..:._Distance fr m foundation"--- _ �_ ------Distance to nearest lot lin ov Number of lines"_"---e�2---"---- ------------Length of each line--------/-0-4----_------Width of trench"-" Type of filter material--" Af?Depth of filter material------t jp!�"""".Total length__.---ter?-!�_: __ __--""""""_.- r age Distance to nearest well--------vT_0-----_Distance from f undation-__--40__""___.Dlstan a to nearest lot�ling.--- ❑ Number of pits------3----------Lining material"-.�-Size: Qi,at�terSV--- Depth__-.---/ling.--- Distance Distance from nearest well__,.-------------Distance from foundation_------------------.Lining.material------------------".--.--_.--------- ❑ Size: Diameter-------------------------------------Depth------------------------------------------- - -- - Liquid Capacity gals. Privy: Distance from nearest well----- ------Distance from nearest bui4.ding""-_"___-"."--""-___-_"""--------.-_.__. ❑ Distance to nearest lot line--------------------------------------------- ---------------------------------G-------------- ti------------------------------- t ---Y- -------------------- Remodeling and/or repairing (describe):""._---_, '�-��-=--"-��"--"-- - -��- -"""" -------------4---------------------------------------- -------------- ------------------------------ --- ------- ---- ---------------------•-------------------------------------------_-.--------------------------------------------------------------------------------------------------------?7------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State l s, and rules and regulations of the San Joaquin Local Health District. ----------------------- ----- �yor Contractor) (Signed) - - •-----` -------- - ------ By:. a {Title) ----- ------------------------------- (P�o# plan, showing size of lot, location of system in relation t ells, buildings, etc., can be placed an reverse side). FOR DEPARTMENT USE ONLY _ -- APPLICATIONACCEPTED BY-------------------------------------- ---------------------------------------------------------- DATE----------------------------------------------------------- REVIEWEDBY-------------------------------- ---------------------------- DATE------ --------------------------------------------- BUILDINGPERMIT ISSUED-------------------------------- ------------------------------------------------. DATE------------------------------------------------------------ Alterations and/or recommendations:----------------------- ---- ------------------------------------- --------------------.......---------------------------- --------------------------------------------------------------------------------------------- ------ --- ------------------ ------------------- ---------------•------------------------------------------------ ----------------------- ----------•------------------ -- II �� 0 - 6 -,� 3.. FINAL INSPECTION BY: t1r Date SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street + 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California 6S 9 nEVkSEO 8.59 3M 3-'63 F.P.C17. r