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FOR OFFICJ,,gE: � 53y 9 sti kNwE 1j,6? 7h_ ---------........._---------- 1-16 -------------------- -----------------------:----------- APPLICATION FOR SANITATION PERMIT Permit No. .........Z....... I (Complete in Duplicate) - ----------------------------------------- his Permit Expires I Year From Date Issued Date Issued --- Application is hereby made to the San oa uin Local Health District for a permvt xnd install x �struc theork herein described. This application is made in compliance with County Ordinance�P_ 549. 17, JOB ADDRESS AND CATION Owner's Name....... e, . &........... -------------------------------------------------- ------------------------------------------- Phone------------------------------------ � � Address------...... Contractor's.-Name-----------•..W-0449-!n-Je49-10-rJ*,e------ ------------------------------------------------------------------- Phone-------•-------I—---------------- i Installation hone---------------I—---------------- Installation will serve: Residence 19-l"Xpartment House ❑ Commercial E] Trailer C F Court _]_--MoteI-E]-7!Other E] Number of living units: . Number of bedrooms 5 "baths xp--- LO --------------- .... Number of t s i fe Water Supply: Public system El Community systemPrivate [] Depth To Water Tab Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loom Ej Clay Loam [3 Clay E] Adobe Hardpan ❑ Previous Application Made: {If yes,date."__________________) 01 ) N New Construction: YNo FHA/VA: Yes E] No El 1 9 es P E] TYPE OF INSTALLATION AND SPECIFICATIONS: (No Septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest,w 11- -----------Dis ou dation.-/0---K-----___.Materi&l--C&--A?-r-1--C.-e---------------- 0;4 No. of compartrr�erlts- --------------- g ----Si Liquid depth........... ---------Capacity-/ -4C2---- i. Disposa�I�F�lcl� Distance from nearest well-WA-6-------74-Distance from foundationNumber of lines_^_..:____ Distance to nearest lot line.. .___. : -.9- - .- , g ------- ............ ----------------- T_,;--- Lenth of each line Af Width of trench. . --- Type of filter mdterial... Depth of filter material.t*----------------Total length_.. .: ------------------------- Seepage Pit: Distance to nearest'well...A91- "_-_Distance fr fou ation-J-0-,..........Clilrary to nearest lot line--S-!.- Number of pits_A- -- - ---------- L.ining material____ -- 0- "-.Size: Diameter_ -X3------ Depth-A41--------------------- Cesspool- Distance from...nearest well-_ 11-------Distance from foundation._._"-------- Size: Diameter----------------------- ----- -777_Depth =`— ------------Liquid Cdipac'ity-------------------_- .....gals. Privy: Distance from nearest well_--.______._____________________________________Distance from nearest building!---------------------------------------- ❑ Y Distance to nearest lot line-_-_________________________ airing (describe]:------------ Remodeling and/or rep! 19-------- ... . . ---------------------- -------------------------------------------- ---------------------- ................--------------------------------------------- ------------------------------------------------ --—--------- ------------------------------------ - ---------------------------- ------------------------------------------------------------------------------ -----------------------------------------*--------------------------------------------_----------------------- -----------------------------------------------------------------I bp I / --------------------- -------------- ...j------------------------------------------------------ ------------------------ --------- I 6reby certify that I have prepared this application and that the work.will be done-in accordance with San Joaquin County ordinances, State laws, and Oes and regul,�"bns of the San Joaquin LocaltHealth District. i (Signed)--------------- ---- ----------- - ---------------------------------- ------------(Ow�,, � Contractor) By:---------------------------------------------- --------------------------- Lell__4�-- ----------------------- --------------- - ------------- (Plot plan, showing size of lot, locatio'n of system in i r ion to wells./buildings, etc., can be placed'on reverse side). Z7 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- ---- - --- ... ------------------------------------- DATE------- —---------- REVIEWED BY---------------------------------- BUILDING PERMIT ISSUED.-.. -------------- -------------------I----------------------- DATE-------- ------------------------------------------ - --------------------------------------------------------------------------------- DATE.----------- Alterationsand/or recommendations:-..-.--•-------------- -------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------- -------------------------------- -- ------------------------------------- -------------------------------------- ------------------------------------- -------------- -------------------------------------------------------- ---------------------------- ------------------------------------------------------------------------------------------ --------------------------------- • --------------------------------- ---------------------I----------------------------I-------------------------------------------------*------------------------------------------------*------------------------------ --------------------- ----------��------------- ---- ----------- ------- - ----------------------------------------- --I--------------------------•-------------------- -------------------------------------------- FINAL INS ECTION BY:.---- ECT" .... Date------------ -- ------------------------- 'SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South Arn*rl,.n-S,t_r**I 300 Wist Oak Street 1freet 205 West 9th.Street 'Lodi,California �,.124 Sycarn6r Stockton,Californiafeta,Clo'liforpla.. Tracy,-California ES 9 REVISED a-59 EM 5-62 ATLAS