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FOR OFFICE US�� _'________________ APPLICATION FOR SANITATION PERMIT Permit No. ..,�C. /1./..... ---------------- ----------------------------- (Complete-in Duplicate) -------------------------- ----------- 'This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. S497 �• t' JOB ADDRESS AND LOCATION---- --._VA ,Q**.4�----�o�._,�•�:-CC��t6,�?L��..t�Q!+�,�•�"��s----'IV�-------------------- 1 Owner's Name +�f= _ ?--- -----••--------------------- Phone---------------•-------•------------ Address-- Contractor's Name--- , '° --------------------- ------------------------------------------------------------------------------------------------• Phon _'.VM.__i_... Installation will serve: Residence ® Apartment House ❑ Commercial "0 Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J-__- Number of bedrooms A3_-_ Number of baths ---j... Lot size --------------------------------------------------- --------- Water Supply: Public ysystem Community system ❑ Private ❑ Depth to Water Table ________ ft: Character of soil to a depth of 3Yfeet: Sand ❑ Gravel ❑ Sandy Loam ❑ -Clay Loam ❑ Clay ❑ Adobe ] Hardpan Previous Application Made: [If yes,date-----------------___ No ❑ New Construction: Yes jX -No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer.is 6vaila6le within.200 feet.) nn JJ Septic Tank: Distance from nearest well-----------------Distance from foundation__Y_4-_-0-------Material-----/I F'�✓- ta_1Pd-___-_--- IM No. of compartments .-_- p ate'- .---;size__3-v-ky-��------Liquid depth_--._3(.20..__-______Capacity_.4..0Q Disposal Field: - Distance from nearest well___.__-__-_-_-__.Distance from foundation.__./d_ -0. Disposal to nearest lot line...j'�___•- Number of lines-----.___ - -- --------------Length of each line__,VAh._1sI"=,4a;0tV.jdth of trench-_____@Z_�._...._.._ ---------- Type of filter material.__. _2.a-f�__-_ Depth of filter material-----14-----------------Total length____:, _�_ ____________________ to See�ge'Pit: Number of pts rest well-��`--_LJp{ng--mDistance from foundation biameter_--Distance to nearest lot line......:.......... Cesspool: Distance from nearest well___________ ___Distance from foundation____.--------------Lining material---_--__.__._______-______________-_ El Size: Diameter---------------------------------------Depth---------- ------------- ------------•-----------Liquid Capacity-----------------------------gals. Privy: Distance from nearest well-_._-_._____ ____ __---__- ____________________Distance from nearest building-------------------------------------------�� _ _ _Distance to nearest lot line_______________________________._____-__ Remodelingand/or repairing (describe)-------------------------------------------•---•----------------••----------------•--•--------------•------------,•----•-------------•----------------- ----------------•--------------------------------------------••----'-------------------------- 4 _______________________________________•_._________»_._._____________-________-__________.___.___--.-.________-_--__-_______________.-....-___________________:_______,_____-____....___-_-.____.___.____..____.___..____ I hereby certify that I 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. e . (Signed)-- —�"� ' A-�-----------------------------------------------------------------------•--•--------------•----- --- ---(Owner and/or Contractor) =Sy:•----------------------------------------------------------------------------------------------------------------------------------ITitle)-------------------------------- ------- (Piot 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----- ^'.� REVI>WED BY - - --------------- DATE BUILDING PERMIT ISSUED---------------------------- ------------------- ----—------- ----------------------------- DATE Alterations and/or recommendations---------------------------------------------------•-•-••----------------------•-...........---•-------------•---•-------... = -----------------•-•- •-------•--- ------------------------------:--------- -----------------------------•--------------------------------------------------------------------••-•------------------------------------•---- .--------•--••----------- FINAL INSPECTION BY:.--- .� -------- Date------. --T'-- 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 REV48EO a-59 r.RCO.2M 6.60