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FOR OFFICE USE: _ ----------------- APPLICATION FOR SANITATION a{ION PERMIT Permit No. ....-- •------------- ---------- ----------- --- ------ (Complete P ) Date Issued . ..�'d •� -_v------------- --- This,Pe'rmit Expires 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 No. 549. $owmA./ teej ) 8f', G� l-7 /¢�RG�ds .�Pi,nGE �.FF /�uyd73 JOB ADDRESS AND LOCATION----- ------------ex......66-7........ •------ Owner's ------U X5'7 f4_if/1C R -•---------•------------------------ ------------------------ Address--_---------------- ----------------•-----Address-------------------•C_=5 raiz-)------------- Contractor's Name.. -� A:..PA.Q IQ J S hF_=0_._�OAIS' IM! ---•----------••---- Phone._11/0.�?.�-6-2-7- Installation will serve: Residence �Apartment`House n Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .__. Number of bedrooms 3___- Number of baths ::_- Lot size ••---•-•---------........ Water Supply: Public system ❑ Community system ❑ Private [Depth To Water Table,10-- ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy 'Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (if yes,date----------_---------) No ET" New Construction: Yes ❑ No-ET"" FHA/VA: Yes ❑ No E]" TYPE OF INSTALLATION AND SPECIFICATIONS: F (No septic tank or cesspool permitted if public sewer is available within 200 feet.) • 1 p k Distance from nearest well___-______-___.-Distance from foundation___________________Material._---__________.___.....____.._______............ Septic anNo. of compartments---- ---------------------Size-----•--------------------------Liquid depth--------------------------Capacity-----------•--•------- Disposal Field:, Distance from nearest Distance from foundation_._ZC...........Distance tb nearest lot line.Z.. 1- -.. Number of lines-------------f------------------Length of each line-------t5 .`.___--------Width of trench----.. - -�Y------ 'L 4 Type of filter mate rial._186 f -------_.Depth of filter material-___-- 1 ----Total length------- -------------------•-- Seepage Pit: Distance to nearest'well---------------------_Distance from foundation___-_-.____..._.---.Distance to nearest lot line_:..____---.____. ❑ Number of pits-----------------------Lining material-------------- ------- Size: Diameter-----------------------Depth-----------------•------.......- 1 Cesspool: Distance from nearest well______-----------Distance from foundation--------------.-----Lining material..__._____--_______.._______.__-____. ❑ Size: Diameter--------------------------------------Depth_-...-.---------------------------------------------Liquid Capacity------------------------•--gals . Privy: Distance from nearest well---------------_------------------------- -------Distance from nearest building-------------------_---------- .------•-. ❑ Distance to nearest lot line--------- -------_---------------------------------- ----------------- Remodeling and/or repairing (describe)----------✓ 6_W------ /fit.---- X/S '`i ------- "--------•----------•----------------------•-------••---- - -- - -------•------------------------------•----------------A ------------------------ ------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County t ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)---------0.----a.----. G `�'°--------!9.r'�..x-----•---------------------------{Ow er and------ /or Contractor) By:--------- ........ ` -�,.`�--- --------------------- [r#le)---------- { (Piot plan, showing size of lot, location of system in=e ells,to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ ----- ------------------------------------•-•--------- DATE----t y '--`' -`----------------------- ----- --- --- ----------------- REVIEWEDBY------------------------------------------------------------------ DATE.. BUILDINGPERMIT ISSUED---•--••---------------•---------------- -- ----------- --------- DATE.._.._.._.. Alterationsand/or recommendations----------------------------------------------------------------------------------------------------------------------------.--------------------------------- ----- ------ ------------- a � _ / f..i-:_--::---- .. ..._._.. 1 ------ ------- --------------------------------------------------------------- --------------- - ----------------------------------------- - FINALINSPECTION BY------------- ---••---_-..-------- -------------------- 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 2M 5.62 ATLAS 14