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/FOR OFFICE USE: rP nI I yi/ C�35� AF---------------- -t_,,3�------ .42'a!a r�3 ------.--- ..__. _a3,rd . t APPLICATION FOR SANITATION PERMIT Permit No. �9 {Complete•in Duplicate] -- ---- -------------- - - ----- -' This Permit Expires i Year From Date Issued Date Issued I Application is hereby made to the San Joaquin Local Health District for a permit to con'tr t and install the work herein described. This application is made in compliance with County Ordinanc No. 549. r v - JOB ADDRESS LOEATIO,N ° --- - - -- --- - - --- 17„ Owner's Name R 6.4f ----- - - - i • �- ---.-. Phone---�-:^-�O__ Address----------•------_- I •---•-------- ---- ------ r --------------------- Contractor's Name----------- - --- - � Installation will serve: Resrden - 'Apartment House ❑ Commercial Trailer,. Court ❑ ❑ Motel ❑ Other ❑ Number of living units: --1---- Number of bedrooms - fi- Number of baths -l-_---�Lat size'_k2-0'X_.. ------------------- Wafer Supply: Public system` Community system ❑ Private ❑ Depth to Wafer Table ...... ft Character of soil to a depth of 3 feet- Sand Gravel i P ❑ El Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan .. Previous Application Made: (I#yes,date___________________ ) No New Construction; Yes El NoFHA/VA: Yes N TYPE OF INSTALLATION AND SPECIFICATIQNSI (No septic tank or cesspool permitted if pubic sewer is available within 200 feet.) � Septic Tank: Distance from nearest well--- :-___--Distance from foundation.-___--- _-- .--- Material ...__---..___--_- . ----- ❑EY.I "06— No."of compartments------------------ ----Size------------:-:----- - ---------Liquid depth------ - ------- =------Capacity--------- -------------- Disposal Field: Distance from nearest well_---__-_--. Distance f om foundafiony-----------------Distance to nearest lot line------_---------- ; ❑�9lCIS'f 6& Number of lines.----------------------------------Length of each line-- ----------_--------------- Width of trench. Type of filter material._...-------------------Depth of filter material-----------------------Total length-- --------------- •------------------ ------------------------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------- _-_ ❑ZiLS�- &Number of pits...:--------------- Lining material------ . .... Size: Diameter.-.-------- Depth Cesspool: Distance from nearest well _.___`-...-_---Distance from foundation-_....- Lining material...................... ------ - ❑ Size: Diameter. __ -__----- ' Depth ---------------------------- ----------Liquid Capacit -------- Y--------------------------?gels Privy: Distance from nearest well.......#--------------------------- .........Distance from nearest b0clin g ❑ Distance to nearest lot Ime .--- = - , --------------------------------- ---------------- -----=------- Re odeINng d/er rep 'ring fdgscrri�e��----_ - ------ = LL.i - - - ------- ---- ---> - 1� f& -- --- c G ----- --r Q _ I he certify +ha have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws/, a d rules and'r ulations o4fheSa oaquin Local Health District. Si ned 9 ----------- ---- -------------------------- -- (Owner and/or Contractor) Title a .. c -d (Plat plan, showing s e of of, location of system in relation to wells, buildings, etc., can be place on revere side). FOR DEPARTMENT-USE ONLY _ M APPLICATION ACCEPTED BY---------------- - .7-----.-------_- ---------------- F c''! --- ---------------------------------- - .- DATE.- ---'2'--�---6�--- ------------- - -- -- ---------- EVIEWED BY---- -------------------- - ---------------- --- -------- ------------------------------ DATE INPERMIT ISSUED---- --- ---------- --- ---- ------- ---------- - - -------------------- -------- ----- -- DATE------------------- --------- --- ------ ----------- ---- Alferat on and/or recommendati s:.-- -_- 41 26 / `� ----------------------- -- -� • /I FINAL INSPECTION BY:------------5 ----------- _ ----------- --- --- Date {6 SAN JOAQUIN LOCAL HEALTH DISTRICT;, .- 1601 ISTRICT 1601 E.Hazelton Ave. 300 West Oak Streetf r 124 Sycamore Street 205 West 91h Street itocklori,California t -Lodi, California Manteca,Colif5rniar • Tracy California E.H.9 2M 1.67 Vanguard Press - r r. L% e