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rUKVFFIGE U5E S ----------------- -------- _ 13 ,�� ..........................................._.____.__._._- APPLICATION FOR SANITATION PERMIT'� tPermit No. ��,__.�� ---------------------- ' [Complete in Duplicate) I'll,`f Date issued .... /�/ . -- ------ This Permit 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. 2�g� eco—C)L/ - T 6 ADDRESS AND LOCATION a .... ........... - .. -----------••---••---•---•-•-•--. .. Owner's Name_ ------- ---- ---•• ------------------------------------------------------. Phone...........•---••-- ............. - Address......... Contractor's Name--------------- ---------_------------- --------•-----------.._..------_--------------- Phone................................... Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1____ Number of bedrooms Number of baths __- size .. �._��__.�.��............................. Water Supply: Public system ❑ Community system XPrivate ❑ Depth to Water Table W--- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel X Sandy Loam 'Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: {If yes,date--------------------) No,;!f-- New Construction: Yes`�No ❑ FH A: Yes 4 No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 ee ,'t Septic Tank,5 Distance from Heaves# well1t c from.foundation___ _.....__.M t fial..( �lt�_.__•--. --•; • [ No. of compartments_.____. ,______________Size... ___ _ . Liquid depth------ --- f`------Capacity..Y..�e--�.___._._. K 2 .✓ / DisW l Field: Distance from nearest well�t9_04 Distance"from foundation..A _ DisT 6 to nearest lot line....... Number of lines_....___________ _____ Length of each line_ Z �� + fl "Ili r , .Width of trench._ ----- --------------- Type of filter rnaterial�M--------Depth of filter material----.��,ei--------Total length_.......-_ r-___ ______________._-- G3 Seepage Pit: Distance to nearest well----------------------Distance from foundation......--------------Distance to nearest lot line-------.......... ❑ Number of pits-•--------------------Lining material---------------•-------Size: Diameter----------•-------------Depth-----------------------------_-.- i Cesspool: Distance from nearest well-________________Distance from foundation--------------.-----Lining material________..._._.____._______...___._._ ❑ Size: Diameter------ •--------------------------Depth----------•-----------------------------------------Liquid Capacity----------------------------gals. Privy::_ Distance .from. nearest•well--------- __�"r _."-'_ _"'-Distance from nearest building 9 ...- -------- Distance to nearest lot line Remo eling and/or epair ng (describe:___ f �.%%r_ 2--- --- b7%.p,e--G t---It" ------------ r ... - ------------------------------------ -------------------------------------------------------- ------- --- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County o4litances, State laws, and ruletjpnd reqWafions of the San Joaquin Local Health District. (� (Signed). ` ------------•------_-------------------------(Owner and/or Contractor] By:----------------------------------------------------------------------------------------------- -------------------------------------(rtle)---------------------------..-..----------------- ---------- (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 APPLICATION ACCEPTED BY-------------------------------- ------------------------ -------- ----• ---------------------- DATE.----- - -- - - -REVIEWED BYDATE f�-..�� --------------- BUILDING PERMIT ISSUED----------------------------------------------------------------------_-- ------------------------ DATE - Alterations and/or recommendations--------------------------------'-- -----------------------------------------------------------•--- FINAL INSPECTION BY--------- -- --------------- -------------- m--.-----,.------ Date-----------�L-------�~ f � �-------------------...__. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street ]24 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California Eft 9 AEV16ED G-89 2M 5-6l ATLAS G