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{ FOR OFFICE USE: ----------------------------- ------------ , / _Z2.. i -tti o APPLICATION FOR SANITATION PIRMI� y Permit No. ....... -------- - ---- --- ------ (Complete in Duplicate) le Date�issued _____� -��-�.-- -__ ------_---------------------------------------__"- ;; ' iThis Permit Expires 1 Year From Date Issued Application is hereby made to the San 11oaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. -549. o�i.5t:'= f JOB ADDRESS AND LOCATION-_:-------- aZ'------------- . jOwner's Name-----A d 4z'n -r L-t-•----- ---------------•--------------------------------------------------- Address------- --------------•--•.Address------- --------1*------�&--------------------5:?a I -------.------------ ------ ------------------------------•---------•-•------- •------•-Contractor's Name-------------- -------------------------- Phonel�� ------- Installation will serve: Residence ® Apartment,House C] Commercial E] Trai�r Court ❑ Motel E] Other Number of living units: --- -- Number of bedrooms _,3___ Number of baths Lot size / .� t- y - •------•- Water Supply: Public system ❑ Community system 0 Private Pg--Depth to Water Table fi-- - ft. Character of soil to a depth of 3 feet: Sand-E] Gravel ❑ Sandy Loam ❑ Clay Loam❑ Clay ❑ Adobe j5 Hardpan ❑ I Previous Application Made: (If yes;date____________________] No F] New Construction: Yes No E] fHA/VA: Yes ❑ No 11 TYPE OF INSTALLATION. AND SPECIFICATIONS:' (No septic tank or cesspool permitted if public sewer islavailable within.200 feet.) Y Septic Tank: Distance from nearest well___ 6"7Distance from foundation------.f�'_""__.Mafeiel-------Ife:el12'o®_________________ ® No`. of compartments_.-•.--.- -------------Size----.3--A_ '-- X _Liquid depth------ --- .--__ Capacity---- I! �` �___.Distance to nearest let line_____.�_�-- Disposal Field: Distance from nearest well-__. _ Distance from foundation-___ ( Number of lines________________ R:__Length of each line_.-d'__ ,P_ � Gldth of trench--------_-2- ----------- Type of filter material_____- ---Depth of filter material___ __Total, length____-�A_�VQ'_______________________ Seepage Pit: Distante_to_nearest1well----_ _------------Distance from foundation__=.-_---._:_.___-Dista'nce to nearest lot line--------.__._____ -------.Linin Material---------------- Size: Diameter Dept : ❑ Number of pits_.-____.__._ �"` 9 � _-- •---- p 4 4 ,ll i Cesspool: bisfance from nearest well`s_______________Distance from foundation-------------------- material.__.______________________.____._____. ❑ Size: Diameter------- '-. -= -------------Depth------------ ---------------------- Liquid Capacity--------- •--4-------------gals. Privy: Distance from nearest.+well-_;---------------------------------------------Distance from nearest building:-------------------------------------- . ❑ Distance to nearest lot hne ry ------------------------------------------------------------------------------------------------------•-------- Remodeling--a--n--d-I-/--o- nd/or repairing (describe).:-----------------' ---------- -----------•---------------- 5 .. F ------------------------------------------ ' ------------ - ------------ - .„ . ------------- _ --------------- ---=------- --------------=---------•--_----•----------- - --------------------------------------- ---------I-hereby certify that��l 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. . i (Signed)-- -- ----=--- ------L------------------------------------------------------------._._{Owner and/orContr actor) By:---------------------------------------------------------------------------- -----L-------------------------•----------------------_(Title)----------------------------------- -- -------- ... (Plot plan,'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 - - --- ------ -- --------------------- DATE . BU LD NG PERMIT ISSUED----- - � -- -------------------------------------------------- DATE------------------------------------------------------ BUILDING - -- - =--=+--------------------- DATE. Alterations and/or recommend ations:.---=-------:=- ------ ' " " 7. �` -- ---------- ----------------------------------- -------------------------- •- ------------- --------- --------•- - .... II ---------- --------•-----------------------------------------•--- ------------------- --------; --------- -----•-•-------•------------ -------------------------- ------------------------ ----------------- •- ----------------•- - ------------------------------- i --- Date------- ----- -- - FINAL INSPECTION BY:------ - -----�--------._. ---�--i�----�� -------------------------------- 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 E6.9 REVl6E0 0.59 F.P.CO.7M 6.60 _