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FOR OFFICE SE: --------------- -------------------------- -_------ APPLICATION FOR SANITATION PERMIT Permit No. ........................ (Complete in Duplicate) Date Issued �� 6 ......................... This Permit Ex ires 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 a. 549. AgV JOBADDRESS AND CAT] N__-- --- --I --------F----X----- �lr---------------------------------------------------------------------------•-----...-----•------------- Owner's Name------ - ------------------ •-------------•-• ---------------------------------------------------- Phone-------------- Address--- --- --- . ....... .................--------------------------------------------------------- -----------•------- Contractor's Name----------- -----------------------• Phone...---•---------------------•------ Installation will serve: Residence Apartment House [I Commercial ❑ Trailer Court El -7 ❑pother 1-1 Number of living units: _/__. Number of bedrooms _;&_ Number of baths /___. Lot size . _ �s/Yd --f--------•---•---•------- Water Supply: Public system 21"Community system ❑ Private ❑ Depth to Water"f4ble _fV ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam ElClay Loam ❑ Clay E) Adobe 2-*'Hardpan E] •Previous Application Made: (if yes,date--------------------) No New Construction: Yes Y�rNo ❑ FHA/VA: Yes 1R No ❑ TYPE OF INSTALLATION ANb SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) = / Septic Ta k: Distance from neares wed_---,_- Distance from ��foundation._Ap--.-----_.Materjl--- - �. No: of compartments__� ._:___Liquid depth_. -------------Capacity._. ___.__ \ r F .��•+ Disposal Field: Distance from nearest�arrell _______________Distance„from foundatio�n-_•-___/p______.Distance to nearest lot line___ .____..__. ®/ Number of lines------Z.---' LAgth of each line___---l� f-__------Width of trench.-,-X_----. __ -••------------------ j pQ _ Type of filter materiat¢.�Z(l --Depth filter material„�______ ZA --__:_Total length.......�r _________________ _________ $I'------— ante from ation___f�_______ .Distance to nearest lot line--ho- Seepage Pit: Distance to nearest we .� Number of pits___.__-1__..__-__;Lining m terial- � __--- ize: Diameter_ --------_.Depth_--- 1________________ Cesspool: t`a ' Distance' from-nearest-well_________________Distance from fo dation._.---_______-.____.Lining material___----_______-________----_________. ❑ !Size: Diameter-------------------------------------- epth---------- ---------------- -----------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------- ------------------Distance from nearest building__---._.______---_________-_________.---_. ❑ Distance to nearest lot line--------------------------------------------------------------------------•-------------------:--------------------------------------------- --------------------------------------------- Remodeling and/or repairing (dostribe):,______._._____`�•(�(,�- �4 = ---------------------------- --------------------------- ----------•--------------- - -•--------••-----------•-•----------------•---------------...---------------------------------- ----------------------------------------------------------------------------------------------- I --- --------- ----•----------- a+ I 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 regulations of the San Joaquin Local Health District. + T /or Contractor) (Signed)------ --------------------------- ------------------------------------------- - 1 By: -- -- ---- ------ {Title]` !?�1- -- (Plot plan, showing size of lot, location of sem in.relation to wells, buildings, etc., can be placeddon reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-------------------------- ------ ----- ----------- ------------------------------------------ DATE -------------------- -2;1'FZ'-J'•------------------------ REVIEWED BY_ --------------- - DATE--------- - -----------------------------•------------------ --------------------- --- ------ - -- BUILDING PERMIT ISSUED ----- ----- - DATE Alterations and/or recommend tions _-- t -� - --------------- - -----f� ' �Q4sp _/ ------------------------------ - --------------------------------- --------------�------- ,••-�--1--- -- GFl /� / g / t '-r✓L- �f �. ---- - ----- f-, y , - -¢� FINAL INSPECTION BY------ -------- -�-=•--:Y-------- ------------- - - Date-------------- --------------------•------ SAN JOAQUIN LOCAL HEALTH DISTRICT, 130 South American Street 300 West Oak Street 124'Sycomore Street' 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES-9 REVISED 8.59 F.P.CO.ZM 6.60 i