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N APPLICATION,TQRI SANITATION PERMIT �� I� Permit No. ___`�--_4_2_- (Complete in Duplicate) /� 1 i >/ �►" I N'" Date Issued ---------- Ap Thiplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. s application is made in-compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION___-_ __ �O i Owner's Name-------�R•N1_UI_�_ � -- - --- ------ - ---J�5_MAI-- ------ Phone Address------------ ---- - - F99-v�----------------------------- -- Contractor's Neme----,p_ // -----------------•---- ------------------------------------- --- ----- Phone installation wil0serve: Residence Jf3o"A�partment House ❑ Commercial ❑ Trailer Court_� ❑ Motel ElOther ❑ f ng units: Numberolivi __Number of bedrooms _t— Number of baths __` Lo# size -____L Water Supply: 'Public system VCommunity system E] 'Private E] Depth to Water Table ------ ft. r 7 Character of soil foe. depth of 3 feet: Sand ❑ Gravel E] Sandy Loam E] Clay Loam ❑ ClayAdobe ❑ Hardpan ❑ Previous Applicafion Made: Yes ❑ I No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ 14 No TYPE OF INSTALLATION,AND SPECIFICATIONS: (No septic tank o cesspool permitted if public sewer is available within 200 feet.) r Septic Tank: Distance from nearest well_________________Distance from foundation_____ ------Material------ ` ------ a STIIV� No. of�compartm�ents------------ ------------Size---------------•----------------Liquid depth------------ ----=--Capacity----------------------- Disposal Field: Distance from nearest ell.7 !- Distance from foundation--- /� 10----------Distance to,nearest lot line--- Numbei'of lines____________!_____________________Length of each line--------/t0__ ' Width of trench_ _--_-- -- -------------------- Type of fitter-materral__ _- � _ ______pepth of filter material___-_1-_�_--____-__Total length--- ----t ZQ________________-____-_ Seepa it: Distance to nearest well___-_�-'__Distance from foundation----/0- .._____. lstan to1nearest lot line-____,�___.__ Number of pits--._-__J_--_-__-_-_Lining material__f30CJ -Size. Diameter__ Depth______ _f _ 99 -- - Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__________________________ ----------- ❑ Size: Diamefer---I-------------------- ----------Depth----- ----------------------------------------------Liquid Capacity----------------------------gals. Privy: Disfan ie from nearest well-------------------------------------------------Distance from nearest building ❑ Distance to nearest lot line__-_________________________ --------------------------- Remodeling and/or repairing fdescribe): --- ------------- --------------------------------- ----------------------'---------- ------- -- ----------------------------------------------------------- r _--: ---------------------------------•-----------------------------------------------------------------------------------------------------•------------------- I herebycertif that I have � __ � - Y prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules andiregulations of the San Joaquin Local Health District. (Signed)-------/----- ----- = t -- ------------ --------------------- ---- -------------------------------------------- ------------------------(Owner and/or Contractor) By:------__--------------------- . Y Title I (Plof pan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------`' ,.R•------------------------------ - - ------- ----------- -------- --- DATE------ REVIEWED --2$----�-- ---------------------- ----------------REVIEWED BY--------------------------------------- -------------- ----------- -- ---------- ----------- - - DATE---------- -• i BUILDING PERMIT ISSUED-! ----t -------------------------------------------------------------------- DATE- Alterations and/or recommendations: t,i-o,n s:_----- ______________________ - . ------------------------------------------ I ---- ---------------------•---------------------•• ---------------------------- ----------- - ----------------- _-- -- �ti_� / /-S (o _ et --____----- --------_a _ FINAL INSPECTION BYY1.._..___�-,-_-/ . Date----------------- -------------------- ---- ----------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT } 130 South American Streat 1 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California I Lodi, California Manteca, California Tracy, California I ES-9-2K4 . Revises 1-57 F.P.CO. i