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FOR OF USE: ---------- �J----- Permit No. ..-�-- --••--- f / �� z , APPLICATION FOR SANITATION PERMIT ' (Complete in Duplicate) Date Issued . ------------------- ----- ------- - -- *This Permit-Ex ires"1-Year"From Date•lssued - Application is hereby made to the San Joaquin Local Health District for.4a permit to construct and install the work herein descn e . This application is made in compliance with County Ordnance No. 549. F p .: - --------------- JOB ADDRESS AND LOCATION...__-- ' ,-_�� pp&o----------.--------`------- - = Phone---- ---=---------•---------------- Owner's ---------Owner s Name___._ - ------------------------------------- -Address - = = -`----------------------------- •--------;-• -------•-------- ---- Phone----------------------------------- e Name. r t I ❑ Installation will serve: . Reside-rice. House`❑' Commercial ❑ Trailer Court ❑ Moe Other ❑ Number of baths .- .--- Lot.size .i�f1Xd Number of living units: --k Number of bedrooms __ /� Water Supply: Public system Community system ❑ Priv'ate ❑ Depth to Water Table _ • ISand Loam ❑ Clay Loam [I Clay ❑ Adobe ardpan ❑ Character of soil to a depth of 3 feet: }Sand C] Gravel ❑ Y Previous Application Made: (if yes-date__.___.-_----- =--) No New Construction: Yes ❑ No ��HA/VA: Yes F] No s TYPE 'OF INSTALLATION AND SPECIFICATIONS: i (No septic tank or cesspool permitted if public sewer is available within 200 feet.) _ ! Se ic Tank Distance from nearest well --------Distance from foundation------------ --------Material ._____________-___-.______._____.-_.._______.... ' No. of compartments--------------------------tSize-------•-------- €-----=---Liquid depth--- ------------ ---------Capacity - Disposal Field: Distance from nearest well________________`Distance from foundation...___...___.______.Distance to nearest lot line--------------- ❑ �. Number of line. = ---------------- -Length of each line-------------- --.Width of trench------------- Type of filter material-------------------------Depth of filter material----------------------- T length---------------.-=--••------ m.. a. . i — ._______.:..Qistance to nearest lot line__.f�-�--- ge pi : Distance to nearest well.- --------- from foundation___�� .� Number of.pits.._.�------------- g Size: Diamete _ r Depth. •ev�_Y�-----------_ Linin material _4- — Cesspool: Distance from{nearest well----.____�-______Distance from foundat.ion___________________Lining material__.___-__________-__.________ ` i Size: Diameter!------ ------- ----- -------------Depth------------------------------------- --------- •---Liquid Capacity------- -----•-----•-----gals ❑ . Privy: 'Distance from nearest �rrell-----------------0._--= °---j--'2',---Distance from nearest.building---------•-----.------------ ❑ ".'" Distance to nearest lot line----------- ------------ ----------- 3 }1 __ _ .__ _ _________- I—— f ~ ________________---__._____---___ _ _.__ _ -. Remodeling and/or repairing (de"scribe):_-_-_- ,----- --- 4 .f -----•----------- -I - — l ---------------•------------ t }_ _ I hereby certify that 1 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' r 1 I , =Y--( fir Contractor) (Signed - ----- - - 11 -� == Ti+le_ By:---------------------------- { , ) G _ (Plot plan, showing size of lot, location of sy in relation to wells, buildings, etc., can be placid on reverse side). ,.. _ ... t. FOR DEPA TMENT USE ONLY f1 , x. --------- ---------------------- -- --------------------- 1 APPLICATION ACCEPTED 8Y_.__,-_._ _______ DATE ' = ._ _ -. _ � i �z DATE----------------------------------------------------------- REVIEWED BY--- --- ---- -- DA T BUILDING PERMIT ISSUED________._._;_�__._.- - j o' a`' DATE.. ---------------------------------------------------------------- d - - _._ Alterations a d/or recommendations:___-__ - �""'"" - - ------- ---i _________________ F ______________c_____-__._____ — t t --------� --------------- ------ ------------ ------ FINAL INSPECTION BY-_- - - - -- _. -� �O /--.--- ---- ------ -------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast Oak Street `i' Q124 Sycamore Stre0i,- ems, 4205 West 9th Street 7racyr California Stockton,California Lodi,California Manteca,California E9.9 REVISED a-S9 r.PSG D.7M 6-fia L j