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4FR OFFI�� _----__--'l--- APPLICATION FOR SANITATION PERMIT . Permit No =.. . l (Complete in Duplicate) i - ------------- --------ON,\-............. Date IssuedV -•--- ----� rThis Permit Expires 1 Year From Date Issued- - ! his lacatl cat onesemadeadeG� ------ ---- ---------------------------------- -- pp y to the San Joaquin Local Health District for a permit to construct and install the work herein described. pp ompliance with County Ordinance No. 549. , JOB ADDRESS AND LOCA --------------- /� f/ 1'g t �S/D3 Owner's Name------------ d------- ...... ._(`_A ut__ fz_tC_ ------••------------------------------------------•----------------•--- Phone. ... Address.................. D, �-!--•..- - ------- - ---- --- --- --------- ----- L -- .. ...__E.�.....7�rr = Contractor's Name-_.- i�- --------------- -------- Phone.. . � � = Installation will server .Residence, Apartment House. Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms _ _ Number of baths ----L Lot size ------6_Q__._ __.> 0 0•xr Water Supply: Publit'system ❑ -Comm u-ity system ❑ Private ❑- Depth to Water Table--_ ft. ] Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam El Clay Loam [3 Clay C1 Adobe Hardpan ❑ 3 Previous Application Made: {If yes,dote----------- ':_..] No X New Construction. Yes X No ❑ PHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: ' I (No septic tank or cesspool permitted if.`j;Wic sewer is available within 200 feet.) r, iG r � / t- �/ + coke. dtr• reJo , Septic Tank: Distance' from nearest w:e'IL�_--1h1n_j.Distanc from tfound�tion__�__A01--._.Materpi------.- --- - - ------------------------------ No. of'compartments..._. .____? ._.._-_.__Size___ ...- ...Liquid depth-------6------------- Capacifiy.._ F I Disposal Field: Distance from nearest well._dr-_a_Ik1A,Distance from foundation../.At--/Jt--..Distance to nearest lot -lY+ rh- Nuinber' of lines--------- _----�----- :__Length of each line_-..__ -Width of trench..____ y.�j- 3__=---_-- `c w Type of filter matenal_a _e ,,_r4c _ __Depth of filter material----J --_,____._--Total length------- �L-..._--- I _ . Pit: Distance to nearest well-.-- _--------Distance ro foundation__10--_--__--_. 'starFe to nearest lot lin ---------- Seepage _ 0 Number of pits----j----------------Lining. material___�n--Z - ----Size: Diameter--- -_5------------Depth____,2S_._.•------------=-- � Cesspool: Distance from nearest weil-----------------Distance from foundation------------------- material-----_.-----__..__-------._:.-------- . F1 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):-------------------------- -----------€-------------------...--------------------------------------------- ---- I1 F l 1R i�. t ------- ------ ------- -------------•-----------------------------------------•------------------------------------------------- k I hereby certify that I have prepared this applicatiori"and that the work will'be done in accordance with San Joaquin County 4 ordinances, Stat laws'and,rules and regulations of 1he.San..Joaquin Local Health District, r�[ A (Owner and/or Contractor) (Signed)------ O II + $Y� - - ----------------------------'------•----'-----------------------(Title)----------- --------------------------------------------------- (Plot plan, showing size'of lot,el000'dnofsystem in relation to wells, buildings, etc., can be placed on reverse side). FOR.DEPARTMENT USE ONLY- * I APPLICATION ACCEPTED BY------------------------------ . ------ ----------------------- DATE--------------/_ REVIEWEDBY--------------------I----------------------------------------- ------------------------------------------------------ ---- DATE. BUILDING PERMIT ISSUED------------------ l remrndations:.___. `—.- - m_ Alterations and/or ---------------- ------------------------ 5 ------ �---------- --------------------------------------------------- u. I - - --------------------------------------------------------------- -------- --------------- - -- - ---- -----•-------------- � . FINALINSPECTION BY,i.---:'---- --- -- --------------- � � 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 r EB-9 REVISED 6.69 F.P.DD.2M 6-6D