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FOR OFFI USE 3•r 3 _ - � - ---- r FOR SANITATION O NAPPLICATION PERMIT PermieNol ---- --- -- ------------------------ �Com tete in Duplicate) Date Issued -------------- '------------------------------- ------- ----g--- --------------------------------- -�^�'" }This'Permit Ex ices 1 Year-From Date Issued ealth District for a permit to construct and install the work herein described. Application is hereby made to the San Joaquin Local H This application is made in compliance with County Ordinance No. 549, JOB ADDRESS AND LOCA ION "� f ---- --- ; — Phone-.--•-_-_---•----------------••-- Owner's Name ----- --------------------------------------------- ----- -•- ,t. -- Address. - --------•-------------------------------------- d y Contractors Name__________________ /'spm+ - Installation will serve: Residence Apartment House ❑ 'Com 'ercial �] Trailer Court ❑ Mote! [3 Other [Im " __ Number hs __l-. Lot size _ e - -------••-----••------ Number of living units: -� Number of bedrooms ��*" Numbeof bat Water Supply: Public system ❑ Community system [�rivate❑ Depth to Water Tab leeft• Character of soil to a depth of 3 feet: 'Sand ❑ Gravel ❑ Sandy Loam❑- Clay Loam ❑ Clay ❑ Adobe[&-�ardpan ❑ 4. Previous Application Made: (If yes,date______________-_---) No Rl�New Construction: Yes El No HA/VA: Yes E] Nom' TYPE OF INSTALLATION AND SPECIFICATIONS: % } (No septic tank or cesspool permitted if public sewer is available within 200 feet.) } — — 1 Septic Tank: i Distance from nearest well---------":____ Distance from;foundation--------------------Material---------------- --------------------------------- No. of coin artments------------------- -------Size__------------FS Liquid depth--------------------------Capacity--------------------..- Disposal.Fields Distance from nearest well___'_`_____ ---_:Distance from foundation____--_- Distance to nearest lot ine--------------___ Ilk Number of,lines____..-__:___-------------- -------Length of each line------------------------- ----Width of trench----------- :-------------•------- Type of filter material------------------------•Depth of filter material----------------_i----Total len gth-----------------------.-------•. - eep Pit: Distance to nearest well_____.e �---___Distance from fou dation_.._�r!___.___.Distance to nearest lot line__ Q r� i Number of pits------ ------------Linin .material., �7 __ _Size: Diameter-JU.----------Depth__.e�.,�`---•------------- "f � Lining'm Cesspool: Distance from nearest well__'_____________ Distance from outdation___-_-______-_ -_ Lining material_____-_---___________-_____________-. ❑ Depth------------- -------------Liquid Capacity------- gals. Size: Diameter------------ ----------- ----------- - ------ --- ----- e Distance from nearest well_______________ ___�_!_-Distance from nearest building_____--.-_____________....___.----------- Privy: ____ -. Priv ----- ------------ ---- - - i ❑ Distance to nearest'tlot line----- ------ --------- € r----- 1 r Remodeling and/or repairing (describe): _. I ------------------------------------------------------------- __________________________________________________ ______________________________________________---------------------------------_ ___________________________________________________________________`____---.-__----___-_-----_---___-.---__------____---__-------..-----_---- --------------------------------- ----------------------- ----- I hereby certify-that l have prepared this-appiicatian and-�that +he work will t6 done in accordance with San Joaquin County ordinances, State laws, and rulespand regulatio of the San Joaquin Local Health District. r ti i - -- Contractor) [Signed}---- • - --- - --- --- -- : ------------- i --- - -------•------------ - - - -- ------•--- ----- --�-- -------- i (Plot plan, showing size of lot, location of system in an to wells, buil in s, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY f APPLICATION ACCEPTED BY-_ -.F -_�.: r, _--------------- ----------------------- DATE----- " �' f------------- REVIEWED BY DATE t ------------- ----------- ----------------- ------------•--- DATE------------------------------------------------------------- BUI LDING PERMIT ISSUED-------------------------------------------------------------------- --------- Alterations and/or reco en ations: --- ------ - ---- - -----------------------------•-------____- ---- Z 1. la_ jrrt •------•----------------------- -- - -- -----------------•----------------------------------------------------------------------------------- ---- Date_..___ 'r- --------------------- � FINAL INSPECTION' BY::_ ..---- ----� ---- AN JOAQUIN LOCAL HEALTH;�DISTRICT* , 130 South American Street 300 West Oak Street V.f 124 Sycamore Street.+�� 1\ 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California EH-9 REVISED H-39 F,P.CD.ZM 6-66