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FOR OFI.CE USE: APPLICATION -FOR SANITATION PERMIT Permit No.9-L3.a-3. --------- -- -- -------------------- --------------- �. -------------------------- -------- —� (Complete in Duplicate) ___ _ This Permit Expires 1 Year From Date Issued Date Issued ��" /_._:Z� Application is hereby made to the San Joaquin Local Health District or a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No ��'A -------- --------------_______ _ JOB ADDRESS AND OC ATION__ _________ _ ___________ _ __ _ "!" Owner's Name-----�� I t � F��S Phone ------------ Address----- ----3------- . --�---------------------------- ----- �--- - - ---------------.------------------------------ --------•--••---------------•--------- Name ------------------------------------- Phone----------------------------------- Contractor's Installation will serve: Residen�partment House ❑ Commercial ❑ Trailer Court MotDel Other El Number of living units: -------- Number of bedrooms 1+�lumber of baths _-,?0 Lot size -- -- !—A�----------------•---------•- Water Supply: Public system ❑ Community system E] Private A Depth to Water Table -- __?..ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date------__-.__--__--) No�. New Construction: Yes)a No E] FH /VA: Yes E] Nox TYPE OF INSTALLATION AND SPECIFICATIONS: -m-(No-septic tank-or cesspool permitted if public serer is available within 200 feet.)_ Septic Tank: Distance from nearest well—lee---Dista fro bbundSJ.on__._.""" "_.____.Mater' I-----_---_ F... ..............�._. No. of compartments--- ,._.____-_._ms�s-.j ize + ---XsS_--Liquid depth---------_ �- -- /- _•7 ...__.Capaci �d_f�: Disposal Field: Distance from nearest well .._Distance from foundation-----""' ___._.Distance to nearest lot lin _--._ Number of lines.��f._ g �►� -- - -- - ----- en th of each line----------------- {-----Width of trench-- _��_ ---- ------------------.- Type of filter material---.--5 �itbepth of filter material----. j.---------Total length--------- ------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------Distance to nearest lot line-._._.--.---.-_ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth----.-.-------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation........._._........Lining material--.-_---_----__.-.--------------_-_--. {] Size: Diameter---------- --------------------------Depth------------- ----- -------------------- Privy: -----------------Privy: Distance from nearest well---------------__-----_____.-.____._...--------Distance from nearest building------------------------------.----------- _ v. ❑ Distance to nearest lot line-- ---------------------------------------------------------------------- -------------------------------------ic-------- ----------------- Rem ehg d r re ring {describe):__ _ "' _�� .► }2 F 2-¢-- ��C�w1.. ----------------------------------------- --- - �------------- ., �Q ----------_-----------------------------------_-----------. ---- I--------•--•--------------__------------------_---- --------------------------------------- ----------- :- ____-___.-__----____ _ ___ _____________ ____ __ __ ________.___________ __________._____________..___._______.__ rr�� -------------------------__ _------___-- I hereby certify that I have prepared this application and that the work will be done in aEc r once with San Joaquin County ordinances, State laws, an rWAs and regulations f the San Joaquin Local Health District. (Signed �- � - � '�`Z--------....................... ---------- ---------- (Owner and/or Contractor) Plot Ian, showing size of lot, location of system -------------N-----------------------------------(-Title)--------------=----------.�-------------- --T- ( P g y in relation to wells, buildings, etc., can be placed n reverse side). FOR DEPARTMENT USE ONLY t APPLICATION ACCEPTED BYE---------------------- ------ ------------- `- - ---- --- ATE----- -------------------_-- ---------- ........ REVIEWED BY--------------------------------------------- ------------------------------------- ------------------ DATE - BUILDING PERMIT ISSUED-------------------------------- -- Alterationsand/or recommendations-------------- --- ------ --------------------------•-------------------------------------------------••--------------•-----------•-------•----• ------------- , .V -/---------------------------------------------------------------------------- -- ------------- --------- -------- - -- -- - FINAL INSPECTION B Date-. --c�-��—�7--------------------------------------------- A J AQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California y F.P.CC. L`