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FOR OFFICE USE- ----------------- ------------------------------------- ----------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. _. - ..?'_ .l� - ------------------------------------------------ ---------- (Complete in Duplicate) L_ - - ----- --- This Permit Ex ires 1 Year From Date Issued 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.' JOB ADDRESS AND LOCAT ON-------- _. ?_ -- t. +.-• r-- -- ---•- -------------------------------- Owner's Name------------ �-` •`-(a7E, --------- ------------------ Phone.,/ Address --------------------------------�----•-•--------------------------------•----------_------------------------------------------------------ Contractor's Naive------- ZL Y ---------------------------------------------------------------------------------- Phone------------__------------------- Installation will serve: -Residence Apartment Nouse ❑ Comm4cialy❑ Trailer Court ❑ Motel ❑ Other ❑ Y Number of living units: _/____ Number of bedrooms .,Al-- NF( eimber`of baths,:'_ •Lot size ...,1�'_ � _. -------------- Water ---__________Water Supply: Public"system M: Comm unity`system ❑ Private NJ Depth to Water'Tableg_ ft.� i ar Character of soil to"a depth of 3 feet: Sand C] Gravel ❑ Sandy'Loam ❑ Clay Loam ❑ Clay ❑ Adobe,m Hardpan [] � - . Previous Applica --tion Made: (If yes,date--------------------) No� New Construction: Yes ❑.�No k FHA/VA:Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: r (No septic tan"r cesspool permitted if public sewer is available within 200 feet.) ` Septic Tank- Distance from nearest well-----------------Distance, from foundation.-....__..__.______.Material------------------------.____._..._----.________- - �Field:'-,;"rrNo! of compartments-- ----------------------Size----------- --------------------Liquid clepth-------------- ...........capacity-•-••----------------, DispDistance from nearest well-- - __.__D.istance from foundation_'./O .'__. Distance'-to nearest lot line__-�i___'_ ❑ ' Number{of lines_______________ _______-----'tgth"of each line________' _ __"______-_.Width of trench.-_- �_ ------------------- •, G_tc`st�iCQ , .. Type of filter material _ -_______ , YP .--------._ •. pth of flier material------1eY---------- Total length � . length-------"-�-'5--------------�-----�--L--!•.-�--.- SeePit: rlarest�ell. 7� Daa froound �m�rto lot line_-.�� . :Number of pits--t - Lining. material 5'zenB __.��._ Dep#h � --------------------� d� to � Q Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_________________________._._..:._.. Size: Diameter' Depth a Xy ❑ 1, p ------- ---------------------- -----Liquid Capacity--------------------------gals. Privy: ,Pbisfance from nearest well--------------------------------------------------Distance from nearest building_______________________________________._. ❑ -Dis#ante to nearest lot line-------------------------------- ------------------------------ Remodeling -------------------Remodelg end/or repa,irin (describe):- -- `--- -; -. ---------------- -• -------- \\\\)) / � •- -- ----- -------- ---- - -- - ----- - ----------------------------------------------------------------------------- -- " -- �` - C= I hereby certify that I have prepared this application and'that the work will be done'in accordance with San Joaquin County ordinances, Stat laws, and rules and regulations of the San Joaquin Local Health-District. 5i ned i 7 ( g )--------�--=----------•--••`-•--------------- -------------------------- -- - � - - - - {Owner ) By:___-------------------------------------------------•-•-•----- -- .-=---------------- --------------------------------(Title)---• ------ -------------------------------- ------- ------- (Plot plan, showing size of lot, location of system in relation to wells, 'buildings, etc., can be placed on reverse side). T) FOR DEPAr RTMENT USE ONLY APPLICATION ACCEPTED BY-- --.-- a-`------- 'z'a----------------------------------•------------- DATE----- - REVIEWEDBY--- ----------------------------------------------------------- --------------------=-------=----------------------------- DATE------------------------------------ BUILDING PERMIT ISSUEQTE.. r� Alteratio a d or ecommendations:-_._ ----- ' hl1 --------------------- ------------------------------------• --==-------------:---------- E n ---•--------------------------------------------------------------------------------- - -- ----- �_ _- .------------------------------------- FINAL INSPECTION' BY------------------------------------------------------=---.------ Date------------------------------------------ C,d' I %4:2 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ti� 300 West Oak Street 724 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California EB-9 REVISED B-59 F.P.CC.2M 6.60 '�