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FaR'pFFICE USE: " 1 --------- ------------------------------------------------ - 3 --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ..1. _.�1�1 � ------------------------------ ------ ------------------- (Complete in Duplicate} / i i -Date Issued - -------------� -------------- -------------------- ------------ -,_ V t Ex ires-1iYear From-tDat`e slued "- -- - - This Perms ,Application is. hereby made to the San Joaquin Local Health Dis�efet fora perms#-to construct and install the work herein described. This �ppllca+iis nide in tom—plime with Coun Ordinance No 549. JOB ADDRESS AND jLOCATION, _ U %j '----41. xj��4� -------------AT-----------� LRTH"TtiO� Owne 's Narne._____.I , "_V --._ -�6 ' 7.& �4__. ------------- tt1 Phone _`.. -� Adiess..___.__ R ---•-------------------- ----------------------Contctor s Name _Ej :-• = - -------------------------- -- Phone----------------------------------- Installation wilserve: Residence Apartment�IHouse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of livin g units: ___T Number of bedroom - ____.Number of baths __%___ Lot size ______________ Wafe Supply. Public system ❑ ,Com,muriity system Privae ❑ Depth•to Water Table _ ft. Chara-ter of soil to a depth of 3 feet. Sand Gravel ❑ Sandy Loam E] Clay Loam ❑ lay [D, Adobe❑ Hardran E]Previous Application Made: (If yes,date_-_________ _______} No New Construction: Yes No ❑ HA/VA: Yes Q No,� TYPE PF INSTALLATION-AND SPECIFICATIONS- V% (Na septic tan-0 cesspool perms#ed public sewer is avatla le within_ 200 feet.)' A ! , r Septic Tank: Distance from no weil____-s?____-___Distance from foundation---.�C_:___-----.Material'-- CR _.jam, b No! ----- -5iZe� ,- - - -- q --------- , ( No: of compartment's_.___ pth______ Capacity__-- d--- )! Dispo al Field: Distance from nearest well_.-_-__.____-Distance from foundation____ __ _________Distance_ nearest lot IinB_=�-kt_. Number of lines-1------- -- -------------------Length of each line------- --- !- C g j, Width i f,, nth,V ----Y� Ir. Type of'filter material_,--- -__CK_.Depth of filter material------- ----------Total leength----_-_--"Q__,-.-- "-.t 1" ••-•-- w ---...„..._.,.. . _ Seepage Pit: Distance to nearest well.______________ ___Distance from foundation__--.___-___--r_-Distance to nearest lot lin __._'___-__--- Number of pifs--)----------_______ Lining materia€____-------------------Size: Diameter----•------•--------•--Depth------•-----�----- -------- Coss --- II -�� .- s Tm_ ®pool; Distance from nEarest we 1_ ______________Distance from foundation---._.__________._.-Lining material__---".__-__-_____ __-______.___.___. Size: Diameter-1 i------------------- ------------"-------Liquid Capacity.. gals. Priv # y• Distance from neaIres# we€I___._-..3 -_:::______"""_________..`__Distance from nearest building____-____.__-___ .. _ ---------------------------------------------------- -•------------- w -- -- istance to near�t lofi line_______________ _ } Rem odeling and/or repairing (describe)___________________ -------- t ------ -------------------"---------•-•------•--•"-- ----------------------•---------------- --------- ==---------------------=-------------------•-------- ---------= I •---------- •- ---------•----------------- ----------------- ------------------------- ._..-=----------•-------------------•=----------•-----------------=------------------------------------------------"-------..._-----------• ------------------ ---- --------------- --- } I�hereby certify that I'have prepared fhis application and that the work'will"be done in accordance with San Joaquin County 1 ordinances, St laws,^and rules nd regulations of the Sari Joaquin Local Health District. Si ned _ ( g ______-.-__(Owner and/or Contractor) -------------------------- `-- 4. y �-`=-�-------- - ---------•----"'='"3'� --_--------•-_"_------- ••--�-=-v"`- =.[•Tit#eY7 (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----- -------------------- ----- REVIEWEQ BY = "`�- _- ` `�" - DATE__ ------------ BUILDING PERMIT ISSUED---- '----•-�! = --------- � DATE: "- ----------- Alt rations and/or recommendations .="__-_- -�'�-_-?__ = - 1 5--�/----------- P_ l c., 14f' = _ ----------------------- --------- �__:_ _.. . ... --•--------------------=--------------------- �-- ---- -- ---h`�-------------- ----------------------------------------------------------- ------------------------- FINAL INSPEC�I BY Date---- -- ----- a— SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 4th Street Stockton,California r Lodi,California Manteca,California Tracy,Callfornia ED-9 REVISED a-59 F,F.CD.7M 6•fiD r