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FOR QFFIE USE: ` r __------ ------------;/� -_ - APPLICATION FOR SANITATION PERMIT Permit No. ----------------------------------- �` f (Complete in Duplicate) _ 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. 76 p z� Sic-"r�" .Q 9 I JOB ADDRESS ANDr ... . -C E 1Q4ef�Phone -`AddhOwner's Name--------- ---- ......... o eri- -crh ----------------------- Address-------------------------------------- ress---------------------------------------- Contractor`s Name. -------- --- ---------------------- Phone-- ... Installation will serve:. Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---1--- Number of bedrooms - Number of baths ---- Lot size __57S__._ '_`7.-R- --------------------•.._.--_ Water Supply: Public system �ommunity system Private ❑ Depth to Water Table7ft. \ Character of soil to a depth of 3 feet:`Sand ❑. Gravel.0 Sandy Loam ❑. Clay Loam ❑ Clay Adobe�rdpan ❑ \ Previous Application Made: (If yes,.date---------------------) No H"""New Construction: Yes No to FHA/VA: Yes ❑ No Vl I TYPE OF INSTALLATION AND SPECIFICATIONS: .4 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic, nk: Distance from nearest well----'_`•------Distance from foundation--/a-----------Material--- No' of compartments------ ---•------.--Size---S`2t_5-------._._Liquid depth--___ftjc------------Capacity-_AO-------- Dispcsa,Field: Distance from nearest well..--_�:.--Distance from foundation.l..i?-------------Distance to nearest lot line_.S _-/------ �/ ! i/ - Number of lines-----------------------------------Length of each line-_---------��?_____..:- Width of trench--a y...-..,-__.---.--------- Type of filter materidl___Y C.-K--.-------_Depth of filter material--- "_"/W_�'�fotal length_--.._----------------------------------- + -_ - _ ; Seepage it: Distance to nearest Weil-------` -----------Distance from foundation--__1_ql_--_ istance to nearest lot line---- Number of.pits_!_-__j--------------Lining material-Voc:.l�_-------Size: Diameter--33�..---.---..Depth-----j.5----__----_------.- r V. Cesspool: Distance from:nearest well-----------__-----Distance from foundation--------------------Lining material------------------------------------- ��J ❑ Size: 13iamefer- = y= Depth Liquid Capacity -gals. ek Privy: Distance from nearest well-----------------------------------------------_Distance from nearest building.-..--.-_-._----___.-._---__------.---... ❑ Distance to nearest lot line---------------------------------------------- ------------ --_E--------------------------------*----------------------------------- Remodeling --`---------•---------------------••---------------------------------- Remodeling and/or repairing {desc�be):----------------------- --- = ---------------------------••--•------------------ I ~ -----------------------------------------•-•------•--•-------•------------------------•--•---•------------ -------•--------------------------------------•----------- ------------------------------------------ 1 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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 regulations of the San Joaqui Local Health District. �q / i Q'LGt- .- 1-f --- -.- ------ --------------------------------------(Owner and/or Contractor) (Signed) ---------''_ �' f/ '� p By: jof ,, - i. = (Title).....PA_A-77Zv------ .............. ...... (Plat plan, showing sizelocation of system in relationewells, buildings, etc., can-be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- ------------------------ r---------------------------------------------- DATE--------------- - REVIEWED BY - IQ W too -- - --------- �--------- ----- ----- --- ----------- --------------�-------------------------------------- �---- RATE:.-.----------•-----•--••---- -•-------------- BUILDING PERMIT ISSUED__------- -------------------------------------•--------------------------------•---•-•---------. DA-TE------------------------------------------ Alterations and/or recommendations:-_--_-_-- ------- ------ - - ---- ------------•-----•------•---------•-•-•- ------------------------------------ -------------------------- --- ----- -- / -------------------- f-1 -------------- f`' �` ter_ FINAL INSPECTION BY:--- _.�., .-.- - _ •= - -- --- -- 2 Date--.- ------••--------�-�----•-------------•- ...--- ## SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street F 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi;California Manteca,California Tracy,California r EB-9 REVIBEO 0.59 F.P.CO.2M 6.60 }