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OR OFFICE USE: y LICATION FOR SANITATION PERMIT Permit No. . -� ��-la.--�--�-- ---- -j----------- APP p� / -------- ------------------------------------- (Complete in Duplicate) Date Issued . "� ---_..______._-- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Heal£h District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No 544. ---------------------------------------------------------____________________________ JOB ADDRESS AND L CATION.._ -- Owner's Na e � '_�__--- - L, Phone.------------------- --------------- ✓ ---------------- ------------ ------- --- Address-- 4- - •-----------•----------------------------- Contractor's Name-------- ----•------ Phone----------------------------------- Installation will serve: Residence ❑ Apartment House Commercial ❑ Trailer Court [I Motel ❑ Other [INumber of living units: A--- Number of bedrooms 2._ Number of baths ai--- Lot size f ---------------------------- Water Supply: Pubiic system Community system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand F] Gravel E] Sandy Loam Ll Clay Loam E] Clay [I Adobe �ardpan ❑ Previous Application Made: (If yes,date__________________-) No W'�New Construction: Yes ❑ No [j;--THA/VA: Yes ❑ No [�J— 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 foundation___________________Material---.------------------.------_--------._________- �i No. of compartments----------- -----------Size-----...-------•----------------Liquid depth--------------------------Capacity------- - ----- Disposal Field: , Distance from nearest well_ __�--r_..._Distance from faundation___� -_.__.Distance to nearest lot line_------- Number of lines---------- Length of each line---{yC.,Q-'---p----- Width of french-: -------.--------------------- �r Type of filter material__, Depth of filter material....�f!-_-�----=Total length___� -_'------------------------- Lo �' Distance from foundation_ _...___.Distance to nearest lot linest�__._--_-__._ Seepage Pit:. Distance to nearest well______ _____ x - ,y ..� Lining material_____ _ p4?_4et.Size: Diamefer_�9._____-- ---Depth_cef--7..__/ .��e � Number of pits__.__/___--_ /�e?p � Distance from nearest well-----------------Distance from foundation-------------------.Lining material---------- ------ 0 ❑ Size: Diameter------------------ -- ----------------Depth-------------- --------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------------------------.- ❑ Distance to nearest lot line- --------------- ------------------------------------------------------------------------------------- :;;Z�_4�0vrrf ------------------------------------ ---- ------ Remodeling and/or repairing {describe}________________ _ � t, ------•-•-----------------------------------------------------------•----------------------------------------------------------------------- -------------------------------------------------------------------------•-------------------------------_------------ ------------- 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 Joaquin Local Health District. -� 047 ------------- r'a►nk/or Contractor] (Signed) By:------------------ . .... -- ------------(Title)- y --------------------------------------------------------- (Plot plan, showing size of lot, location of system in tion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- <- ------ ---------------- ------------------------------------------- DATE----�� 41-r ---------------------------- - - REVIEWEDBY.----------- ----- - ------------- ---------------- DATE----------•------------------------------------------------ BUILDING PERMIT ISSUED- ----------------------- ---------------------------------------------- DATE---------------------•-------------------------------------- Alt tifsand/or rle�comme.... .. ns: -- ---pl��.----- '-- - ------------------------------------------------------- ------------------------------- ---------------------- ------------ ------------- --------------- -- - FINAL INSPECTION BY--_ ________ ____ ______ _ Date- -/ --------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California FS 9 REV$$ED 6.59 3M 3•'63 F.R.CC. \i r