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FOR OFFICE USE: 3 � Permit No.------------------ ------------------ ----- APPLICATION FOR SANITATION PERMIT - -------------------------------- (Complete in Duplicate) Date Issued �"`--------------- --------------------- `•r=--b f --------------------- ----- ---------- . "" _"_- This Permit Ex fires 1 Year From Date Issued ---------------------------------------------- - A -lea---- is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. ;hisapplication is made in compliance with County JOB ADDRESS AND OCATION"- -- ---------- ' ;, --------------- K. -------- Phone Owner's Name. 22 �ff 1 ---- - ----------------------- - ------------• ----------------------------------- ---- ----•---- -•-----•----•------- Address.------- rJ Phone ---------•------- Contractor's Name-------------------- - Other Installation will serve: Residence artment House ❑ ommercial ❑ Trailer Court ❑ Motel ❑ units: ---I---- Number of bedrooms ."_s�. Number of . of baths --- _-. tot size Number of living _i5_y ----- ----- : Publics stem ❑ Community system ❑ Private ISI' Depth to Water Table .�- �fi• Water Supply Y f !y' \\\ ClayLoam ❑ Clay ❑ Adobe Hardpan Character of soil to a depth of 3 feet: Sand El Gravel 13 Sandy Loam❑ New Construction Previous App y - : Yes No [IFHA/VA: e5 ❑ No Application Made' (if es,date ----------- 1 No - y TYPE OF INSTALLATION AND SPECIFICATIONS: ; orseptic tank,or,cgvs opl= ermined if,p..ublic se er.is available within,200 feet.) _ d Ma en I_ y Capacity ��a--- Septic Tank: Distance from nearest wel4_.- ---Distant fr�of' -r4F Liquid de th---"� P ty"' " �-Size Xla" JL - G p. No. of compartments"__"�------ -- �-- Distance from foundation-------------------- to nearest lot line----------------- Disposal Field: Distance from nearest well-- - ---- Width of trench--f&".-",--------------------- Length -----------_----_-. Len th of ----.7,_Width Number of lines"_._ g -------------------- �.=_Depth of filter material------ - -- ------Total length of filter ma teria4_ t"dF''-�t _ Seepage Pit: Distance to nearest well-- Linin--""maate material Distance from founds ze Diameter-------------- -Distance #--DneepthSt lot line-__-------_------ ❑ Number of pits-'#--------•---------- g Distance from nearest well----------------- from foundation"".-"___"-_____.--.Lining material--------------------------------- Cesspool-, Cesspool: Depth----------------------------- Size: Liquid Capacity, - gals. ❑ e from nearest ui i - Diameter---------------------------- c------------------ --- an •.,.R - bald ng Distance from nearest well :" Privy:� � _------------------------------------------ - ''___ '` ----------•--------------------------------------------------------- .Distance to nearest lot fine`Y - ,� ---------------- -- - + -------------------- (d --•--tl 'L fRemodelingland/or reainng �de,cnbe]y------ iL_ j_`' -------------------------------------- p` =1-------------------------------------------------- - -Joaquin I ----------------- - I hereby certify that I have prepared �a}ions application the$an Ja�quinhLocalkwill Heal HealthDistrict.trig{n accordance with San Joaquin County ordinances, State laws, and rules and regulations �� k (Owner and/or Contractor] (Signed) - - _. - -=---- - - �. .� _ --------AA tle) .--- ------ --------- 1111 - _.. =_�- -- (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 IDATE_---------------------------------------- •--------------- I APPLICATION ACCEPTED BY---------------------------------------------- ------------------------------------ DATE-- �-- =�f ----------------------- REVIEWED BY-------•--------------------- ------ / DATE----------------------------------------------------------- BUILDING ----- -------------------------...----------------------------- BUILDING PERMIT ISSUED-----_---------------------- ------ - lr Alterations and/or recommendations:-_"--_"-- -". -- ---- - ------- -----------•-------------------- -------------------------------------------------------------------- --------------- - ----------- ---- ".. "I _.- -6 4---------- Date------------ - FINAL INSPECTION BY:.----- '- ---- F SAN JOAQUIN LOCAL HEALTH DISTRICT 124 Sycamore street 205 West 9th Street 300 Wast Oak Street California Stockton,California 13o South American Street monteco,California Tracy, Lodl,California f EB"9 REV,S60 8.59 F.P.CO.2M 6-80