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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. _.�..�-5--•-- / ------------ (Complete in Duplicate) Date Issued a --------- -------- -------------- ---- --- ------- This Permit Expires 1 Year From Date Issued A lication is hereby made to the San Joaquin Local Healfh District for a permit to construct and install the work herein described. This application is made in compliance with Coun�10_lrdinance No. 549 ---..� - •------•----- Owner s Name------••-- ----•------•--- ---- -•-•----- ----------------•--•------------------------- Address----------/�2iz---- y Phone..------ - i Contractor's Name---------- r Installation will serve: Residence [-Apartment House E] Commercial E] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _L--___ Number of bedrooms .__2Number of baths _._1_- Lot size -------- Wafer Supply: Public system Commuriity system ElPrivate ❑ Depth to Water Table a Adobe�Fardpan E]Character of soil to a depth of 3 feet: Sand ❑ Gravel C3 Sandy Loam El Clay Loam ❑ Clay ❑FHA/VA: Yes ❑ No e— TYPE Application Made: (if yes,date_________________--) No 2�New Construction: Yes R--No ElTYPE 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-----------------------------._____------------- No. of compartments---- --------------- ----Size__.-----------------------------Liquid depth--------------------------Capacity--------•---- ---•---- Disposal Field: Distance from nearest welly----.Distance from foundation..__/.�-----------D+stance to nearest lot line__..____..._ ,�R Number of lines---- Length -- of each line-------_gam? ---------.---.Width of trench.---rY ;'"----------------- V f ' Type of filter material-_ �S' --------Depth of filter material------ Total length______3 ____---•.-----•----- ______Distance from foundation_ _Q_c�m'sh--..Distance,to nearest lot line__S__-.----- 00 Seepage Pit: Distance to nearest well.-/ �- 3 °c -----.Size: Diameter- "'�� -Depth Number of pits-_--_'1+-------_____Lining matenal__�- --/� r Cesspool: Distance from nearest well----------------_Distance from foundation--------------------Lining _mater _ia l------------------------------------ ------------- _--_-.____ __-._______ __.________-. - Liquid Capacity Size: Diameter __-. -------- --- -------- --.Depth--------------------------------------- El ------ -- ------------ ❑ are building -- ----- -- --- _._ ____ _._.. Distance from ne Privy-. Distance from nearest well ___ _____ �— ---------------------------- ❑ Distance to nearest lot Ime--------- ------------------ --------- --------••---------- Remodeling and/or repairing (describe)------------------------------------------------------------------- • x ------•---------------------- -------------------------------- -----------------•----•------ ication and that the work will I hereby certify tlawshaandhave rulespanda egullThesplf San Joaquin n L cal Heal heDistrictn accordance with San Joaquin County ordinances) t --------------- -------�--------- ----------------------[Owner and/or Contractor) ft (Signed) -------------- ----- -- ------------- --------[Title)--------------------------------------------- ------------ By:-----------•--------------- - -- - -- -- - --- ---- -------------- C ------------ 9 P [Plot plan, showing size of lot, location of system in re anon to wells, buildings, etc., can be laced on reverse side). 4 FOR DEPARTMENT USE ONLY + •� APPLICATION ACCEPTED BY------- ----- --------------------------- DATE = y --- DATE---------------------------- ------------------------------ REVIEWED BY----------------------------------------------•-------- ------------ --------••-- DATE PERMIT ISSUED____________________________ --------------- ----------------- --------------- Alteratio s and/or recomm natio --------------- ------------------------- d +� 3 -- ----- - . • � ��,.r..r�. "' . � �------•----•--=�-;----•- ------- --- --------7-------------------- - ----- -- - --------- ------------ii.,W �] - ------------------------- FINAL INSPECTION BY:...---- -. -- - ------- Data ` pr od SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 124 Sycamore Street 205 west 9th Street 130 South American Street Tracy,California Stockton,California Lodi,California Manteca,California EB-9 REVISCO 8.59 F.F.CO.2M 6.6G