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FOR OFFICE U : _ APPLICATION FOR SANITATION PERMIT Permit No. ..... 5..��2 ---------- - (Complete in Duplicate) l ! ` -----------------------------------_-----..----.----.--. This Permit Expires 3 Year From Date Issued Date Issued --- ----------- -------------- __ Application is hereby made to the San Joaquin Local He th Dist for a permit to onstruct nd install the work herein described. This application is made ' compliance with County Ordi ante 549. JOB ADDRESS ANYIATIN---l•p f �j Owner's Name-- --- Phon ...l'J_ ----� " -------- ------------------------------------------ Address----•••--••---•--------- -----Contrector'sName -- '�.-•-•----- • �--„y�--�--� ------ •F- --�.. -- •----- Phone - ... Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ x Number of livingunits: --- N ber of bedroom_-_ Number of baths /.... Lot size --- , �.`.-.- ----.1-- 6------ Water Supply: Public system Community system ❑ Private ❑ Depth to Wafer Tablo�_ tt. i a depth of 3 feet: Sand Gravel San Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Character of soil to p ❑ ❑� Y Previous Application Made: (If yes,date--------------------) No New Construction: Yes ❑ No FHA/VA: Yes ❑ No ❑ -v IC TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se.ptic ank: Distance from nearest H_ /h ista fpm u c tion L�.�__-.._-..Mate ial ............................. -..-. No. of com artments_ -------------S;ze-_-___ . ._3 . .... Liquid de�?t�-..... ---- ; -.-.--Capaci x¢11' p ,,-`` 7C r ... Y cf Di spo i Field: Distance from Weare t well-�Y4�-_Distahcb7rom foundation.vx .-Q......-.Distance to nearest lot line-_�`_. -� Number of lines___- _-__.-_-_-- . -_Length of each line-- -__-- Width of trench ............... Type of filter material.- ----_- Depth of filter materia �_--Notal length....,1- ----------------- -` Seepa a Pit: Distance to near ---------Distance from foundation..... 8.._-_.Distance to nearest lot line_---.._- ✓”` s Number of pits.... ------------Lining material---eQ-c�------Size: Diameter---_,,�-��--_-Depth--------- �-1�--------- Cesspool: Distance from nearest well----------------- from oundation--------------------Lining material----.-.-.-------___.._._.------.____. ❑ Size: Diameter--------------------------------------Depth----•----------------------------------------------Liquid Capacity---------------•-•--_-•---.gals. Privy: Distance from nearest well------------------------------------.---- ------Distance from nearest building-----------___-----_---____----_.-..-----. ❑ - Distance to nearest lot line--------------------------------------------- --------------------------•- ---•---••------•---------------...-----•------------------•-------- Remodeling and/or repairing (describe)-------------- -- --- -- -•--- --------- - --------- - .---- --------I——...-- I hereby certify +hat I have prepared this application and that the work will be done in accordance with San Joaquin County ordinan aws, and rules and regulations of thp San Jo uii ealth District. p� p ------------------ Contractor) [Signed} /// r_""" BY:......------------------------------------------------_------------------ - -----------------(Ti+Ie} (Piot plan, showing size of lot, location of system in relay to wells, buildi gs, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------l' ---------------------------------------...-_. DATE----- `------------------- REVIEWED BY------------------------------------------------------------------------------- -------------------------------........... DATE. ------------ ---------- -------•----------- ------ BUILDINGPERMIT ISSUED----------------------------------------------•----------------------------------------•-----•-•-• DATE.---------------•-------------------------------------•-- -- Alter ti ns d/or recommnd'ations:--_----. .__-.- I/ --------- -' ... I '---,. ..... - 1 _/FINAL INSPECTION BY:--------- ---''----�- ---�- ------------------• Date----------- .� --------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVIs ED 5-99 RM 6-61 ASLAS