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FOR OFFICE PSE-- �- �-= ) r APPLICATION FOR SANITATION PERMIT Permit No. ...L. --------------------------------------------------- (Complete in Duplicate) 14 --------- _ --- -------. _ 'This-Permit'Expires 1 Year From Date Issued ----- Date Issued _ Application is her by made to the San Joaquin Local 'Weal#h'District for e`permit to construct.and install the work herein described: 'This application is made in compliance with County Or dinance No. 549:'} JOB ADDRESS AND OCTION`- __ --- +? w ` ' ----------------------------------------------------- -----------• r Owner's Name-- - •-----••-•- ------------- '- = Phone. t Address------------ -------------------- --- ----- - - -�- - - - - ••-----------••••--•- ------------------------------- ------------•------ ".. Phone................Contractor s Name Installation will servei Residence ❑ Apartment House ❑ Commercial ❑ Trailer @=Fr* Motel ❑ Other ❑nn Number of living units: __Z Number of bedrooms A--- Number of baths __/--- Lot size ------------ Water Supply: Public system eo om riity system ❑`Private..0De to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy,Loam C)-� Clay Loam ❑ Clay ❑ -Adobe[13OlHardpan i Previous Application Made: (If yes,date----------- _-----1 No�/ New Construction: Yes ❑ No �HA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-------Distance_ from foundKation\Ae------Mater's I___+�°_�.�_ ` ----------------- I No. of com artments.___. �` P -- - Size_�X--=x Liqu depth -� Capacity Q I J +a yil , f T ` of f 4., Disposal Field: Distance from nearest well,_.et�C�_----Distance from foundation__ 0-.. ..-_Disfiance to nearest lot line_Q�........... Number of lines------ -_-_ _ Length of each line------ ________Width of trench-- ` __- :.________-__-. T ar Type of filter mate nalf�LTrT Depth of filter material_-_- --- -_-_Total length----9,47..._-_--------------------- ".✓ /� i O� Seepage Pit: Distance to nearest well----!Y-.--------Distance fr m fo ddtion___.Ae..____.Distance to nearest lot line----------------- Number of pits------ ----_--_-__Lining material._/ .Size: Diameter.- ------Depth-rZr*-------__________ \ _ _ ,Cesspool: Distance from nearest well-----------------Distance from foundation----------------- Lining material-----------------__---------_------_-. ❑ \ Size: Diameter € - ------Depth------------------- --------- ----- --- --Liquid Capacity---------------------------gals. Privy: Distance from nearest well------------------------------ --------- -------Distance from nearest building------------------------------- ------ [f Distance to nearest loft line------- ------------------------------------------------- --------------- -•------•------------------------------------------- ----- l Remodeling and/or repairing (describe):--- ------ --;.. -----•---------------------- �rr� - •----•--•----•--•-------•----•---------------•-•---------------- ----- --- ----- 1 i ------ ---------------------••-----------------•-••----------------------------------- I hereby certify thaf(..have prepared this application and'that the work will be done in accordance with San Joaquin County 1 ordinances, SFate laws, an rules and regul4tions of the'.San Joaquin Local,Health District. � .. ( igned)-------- --�--- - ----• -- - -- - -� ---------------------- •- - - ----------------------------------- State -------- - -- --------- ----[ r Contractor) S BY:-------- -----------------------------•- ------------------- ---J(r 1e} �`�"- tjr (Plot plan, showing size:hof.lot;location of syste n relation-to wells, buildings, etc., can be placed on reverse side}. r FOR DE ARTMENT USE ONLY - APPLICATION ;ACCEPTED BY------- ------ •----------------------- DATE-• 10--_"r- l -------------- REVIEWEDBY----------------------------------------------- -------------- DATE----------------------------------------------------------- BUILDING PERMIT ISSUED-------------- -----=--- DATE Alterations and/or recommendation s:-_-_____________ .. ------------------• ------------------------------------------------------------------------- ------------------------------------------------•------------------------------------------------------------------------- ... r ----------------------------------------------------------------------------------------------------- •-.------ ---------------------....... -------------------------------------------•---------•------•-----•---- ----------------------------- - --------------------------------- ------------------------------------------_------------------I---------------------------------------------•--------- -------------------------------•----------------- r' FINAL INSPECTION BY:.- .,:_-_ _. ---- -------- � Date ----i------------------------------------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Qak Street. '9'� \ 124 Sycamore Street 205 West 9th Street Ix Stockton,California Lodi,California ' Monteca,California'I Tracy,California !° EB;9 REVIBEO 8.54 F.P.E[I.2t+1 6.6C