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FOR OFFICEi --- -------------------:---------------------------------I[... -- 11° APPLICATION FOR SANITATION PERMIT _ Permit No. ... fJs y------------- _- r,R�-�- �(Cop piete`in Duplicate) Date issued -- _-- --- - - y This Permit Expires 1 Year From Date Issued �--�tplication is hereby made!'o 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. �0, y JOB ADDRESS AND LOCATi N_..__ % Z3U,2e�--_____-•• I'II `` M7 - ----------- - E` ' i.o►�C-' ----- - Owner's Name----- •----- -------•-4�I-- rih-------- S5w`• -----------•--- --------------------------------------------- Phone------------------------------------ Address-------------------------- --------•-•-- --------------------- Address------------------------- I ?------------ ?kY ...4:9W-e.----R10 ------------- ---------------------------------------------------------- •-•--•-----•---- Phone--------•--•----•--- - --- T Contractor's Name--------------=-�------------ _ ------ � Installation will serve: Residence [Apartment House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units; ----j__ Number of bedrooms __ ___ Number of baths _-_�:]-_ Lot size ___ '> ____________________________________________ Water Supply: Public system ❑ Community system ❑ Private [.Depth to Water Table _. __ ft. ' -Character of soil-to-a depth' of-34eet:-Sand ❑r:G.ravel 0 :,Sandy Loam Z5CIay Loam-❑,_Clay ❑ Adobe [:].,Hardpan [3_ Previous Application Made:i (If yes,date------------.--------) No ❑ New Construction: Yes ❑ No ❑ FNA/VA: Yes ❑ No❑ TYPE OF INSTALLATION ANb SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) t Septic Tank: Distance i from nearest well __5D-__.___Distance from foundation-___Z n____.___-Material----.CQAX!;� + ___..___-_-__. i No. of compartments-------��`_____________Size------ ----Liquid depth----.-_I'l - ''----------Capacity-., Capacity-/`- Disposal Field: Distancel�from nearest well_. -------Distance from foundation-----13;�--------Distance to nearest lot line___`__________ ❑ 'lof lines----------5�._._.___nn Length of each line----------- Width of trench---_�------------------------ I� ---- Type of��ilter material-�!•__ C-------Depth of filter material___ _�___.__._Total length--------I 0---------------------- ") Seepage Pit: Distance,to nearest well----------------------Distance from foundation------------------- Distance to nearest lot line----------------- . ❑ Number`;of pits------------------------Lining material-----------------------Size: Diameter-----------------------Dept h- - -- -- - ----------------- Cesspool: Distancel,from nearest well-----------------Distance from foundation------------------- Lining material--------------------------------------- .SII. n ❑ Size: Dia-meter--------------------------------- ----Depth----------------------------------- -------------Liquid Capacity----------------------------gals. ) T Privy: Distance from nearest well-----------------------_-------------_-----------Distance from nearest bLCIding------------------------------------------ �. ❑ Distance;to nearest lot line------ ---------------------------------------------------------------- --------------------------------------------------------------------{ Remodeling and/or repairi Ig (describe):-------------------------------- ----------- -------------------------------•--------------------------------------------------•------------------------ Ill f'� - --- - ------- - ------------------------ill-------------------------------------------------------------------------------------------------------------------- --------------------------------------------------- ---- ----- ------------ ------------------------------------------------------------------------------------------------------------------------------------------------ --- I -I hereby certify that I Neve prepared this application and that +he work will be done in accordance with San Joaquin County t ordinances, State laws, and 1�rules and regulations of the San Joaquin Local Health District. -. _ . I Signed _---'______________ ___________ _-.(Owner and/or Contractor) BY: ^�` { Title - - -•- - -•• :; ,. : ------- - --------- ------- } (Plot plan, showing size of Id , location of system in relation to wells, buildings, etc., can be placed on reverse side). DEPA TM�VSE ONLY APPLICATION ACCEPTED�BY. DATE REVIEWED BY---------------------- ------ -------- ---'------------------ ------- ---------------- ----------------------- --------- DATE--------------------• - ----------------------------------- BUILDINGPERMIT ISSUED--------- ---- -------------------------------------------•--------------------------------------- DA•TE--------------------------------------------i--------------- Alterationsand/or recommend ons------------------------------------------------ ----------------------------------------------------•-•-----------------------------------------••--------- -----------------------------:-----------------------------------------------------------------------------------------------------•----------•---•-- -----------------------------------------•---------- --------------------------------------------------------------------------------------------------------- - -----•------------------ -------------------------- ---------------------------------------------•--------------- ------ ----------:--------------------- °- FINAL INSPECTION : �- rL� ---------- Date__...'�-L�oB - = N JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th street k Stockton,California Lodi,California w Monteca,California Tracy,California F P.CC. 4i