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FOR OFFICE _ - ------------------------- ---` / " " APPLICATION FOR SANITATION PERMIT Permit No. , -VN -- -"-- (Complete in Duplicate) Date Issued ._..--? -•� ---- ""i .,"._"_,--- Thii Permit Expires .l 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 descrbed. This application is cn lde in compliance with County Ordinance No. 549. CA( AVSTi'� RD t j� jf M) I_>= 1>� c� iF ,ate �F)— JOB ADDRESS AN OCATION_-' J--�..f--'--f-f-#iNT--------.`al.T?,1-._dF---AT!1a-T-------•--• W�.i-1 M ----- Owners Name- =------- - �-'--------- - ---- - ---- ---------------------------------------------- Address-- � J� �---------------------------- •-------------•--- --------•-•--•••••---•--••----••-------•------- .......................................... ------- - ---------------- Phone----------------------------------- Contractor's Name ------------ OW11( R......................................------••-•-••-•-••------........ OWNER -----•----------- Installation will serve: Residence artment House ❑ Commercial 6- Trailer Court ❑ Motel C] Other ❑ �7— �. x_...3..'3.0..---...._... Number of living units: -1 _____ Number of bedrooms _Number of baths ______.. Lot sae ...♦♦.� ---- - •--- Water Supply: Public system ❑ Community system ❑ Private ��DeptlL,to`'.Water. Tablelz7ft. Character of soil to a depth of 3 feet: Sand. Gravel ❑ San y Loam Clay Loam [3Clay ❑ Adobe ❑ Hardpan C] Previous Application Made: (If yes date--------------------)_ No New Construction: Yes o ❑ FHANA; Yes ❑ _ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ®___.Distanc fro foundation.__ .._.__..Mat ial...rl/-C% Septic nk: Distance from nearest well __. id Ca acit V0 u No, of compartments.._._ _�ylz,,i - ------Size_/.% -k._ Liquid depth-•• P Y Disposal Field: Distance from nearest well --_ Distance from foundation.-. .Distance to nearest lot line. Number of lines ----- -------- j____ ----------- Length of each line.,'' _`! _ idth of trench. •--�� - ............ Type of filter material _.i?4..%�i---- Depth of filter material____.i__ ____________Total length___.�.�17__._ Seepage Pit: Distance to nearest well__ __-.____ _Distance from foundation .................... Distance to nearest lot line_________ ____ ----Size: Diameter Depth---------------------• -- ----- ❑ Number of pits_____________ ___ Lining .material .______- --••------•--- Cesspool: Distance from nearest well ......... ......Distance from foundation --------..... Lining material -------------------------------- Size: Diameter.-•---------•------•-------- .._.. ❑---------- Depth ----------------------------------------------- --Liquid Capacity ---------------------------- Privy: Distance from nearest well ___.___" ----------- --------- _________"_Distance from neerest building___" -__---__-"_________________"-_____,_-- Distanceto nearest lot line ------------------------------------------------------- ---------------- -...................................................................... Remodelin and/or repairing describe) ___ ----- - ------ �� 1_ - _ m -- - ------ 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 regulation of he Sa Joaquin Local Health District, _ _. :`:(Owner and/or Contractor) (Signed) . (Title) ---- ----- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY ..R--- DATE... APPLICATION ACCEPTED BY -------- --f ._c -l1 `Q REVIEWED BY ------------------ -•-------------------------..-------------------------------...------------------------•--------------•----- DATE ------------------------------------------------------------ BUILDING PERMIT ISSUED------------------------------------------------------- ---------------------•----------------------- DATE ------------------------------------------------------------- Alterations and/or recommendations:-------�----------------------------------------------------------------------------------•------- -----•-----•---------•--------------------------------------- I ----------- ................................................................................................. --•----------------------------------------------------------------------------------------------- -------- I ...... --------- -------------------------- .......................................................... -------------------------- ---"---------------------I............ ��------ FINAL INSPECTI Date•--�-------- � - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton, California Lodi, California Manteca, California Tracy, California ES -9 REVISED 5.59 F.P.CD. 2M 6.60 -