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FOR OFFICE USE: 5 - j + APPLICATION FOR SANITATION PERMIT Permit No. _ F ------------------------------------- ------------------ (Complete in DuplicateDate Issued Duplicate) Date ---------------------------------------_._-_ This Permit Exa ires;;i Year From Date Issued •_-f �- ---_4 Application is hereby made to fhe San Joaquin 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. JOB ADDRESS ANJL CATION- Ilk '` V %p I rbi.-�1 Owner's Name 5 --------- Address-----------------•---- - Contractor's Name-----------------\RtA -------'�1 ,13,0 --------- ---------------------- Phone---------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _-I____ Number of bedrooms - _ Number of baths!-------- lot size --- --1 .. = c ---------------------- Water Supply: Public system ❑ Community system ❑ Private ®"'Depth to Water Table4-'-- 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--------------------J No- ew Construction: Yes ❑ No �HA/VA: Yes ❑ No�� TYPE OF INSTALLATION AND SPECIFICATIONS: ... � (No septic tank or cesspool permitted if public sewer is available within 200 feet.) `-,...�- -— ,� Septic T k: Distance from nearest well--$ Distance from foundation-�Q--- - ------. Matefial-1- No. of compartments------ _--- ---_Size--- ' O-----Liquid depth_- !--A� ------------Capacity-----j ------ re ----- -- Disposal field: Distance from nearest w II-. -�- -Distance from foundation.- -!__--.Distance to nearest lot Iine �-_�._-.__ f Er Number of lines___--------1-----__f_-- ength of each line----_ �--'._--_--..Width of trench-- -.Y-_.j-------------- Type of filter rrnaterial----- % epth of filter pg material_____/d .r�---.Tota€ length_--- -------------------- i See a it: Distance to nearest well...-zj __f__Distance -l —m foundation___ .._.__Distance to nearest lot line --- " Number of pits......)-------------Lining material_ -._-.-.Size: Diamete r^5.'�X------Dept lt:'?_-4-_ Cesspool: Distance from nearest_well_-_----,r,_T.__Distance from foundation____________ ____Lining material--_------__--.--_---_____- _----.-_. ❑ Size: Diameter------------- ------------------------Depth- ------------ -- ---------- --------------------- Liquid Capacity. -------------------------gals. Priv Distance from nearest well--------- "'--------- ._Distance from nearest building ❑ Distance to nearest lot line------=-------------------------- --------- - ------------------------------------------------------------------- ------------=------------ h Remodeling and/or repairing (descrilJe): --- -------------------------------- .D r ------------•-------------------------------------------- ----------------•----------------- -----------------------------:------- I � , ---------------- -----------------------=-------------•----------------------------------------------------------------------------- ----- :F I hereby certif that I have prepared this application and that the swork will be done in accordance with San Joaquin County ' ordinances, State`ia s,.and r fes nd regulations of the-San Joaquin Local Health District. (Signed)------- -- :- - -- -- - 1 - - -�j - -----------------------�' ------------------------------------------l {Owner and/or Contractor) By:--------------------------- t✓laC!/�4 ' --------- --=------------------(Title )--- J_le�Ysr (Plot plan, showing size of o , location of system in relation to wells, buildings, etc., can be placed on reverse side). i FOR DEPARTMIENT10SE-•ONLY APPLICATION ACCEPTED BY------�i - 5 '-: ° -- -------------------- --------------- DATE-----tet REVIEWED BY = f -------------------------------------- DATE------------------ BUILDING PERMIT ISSUED------------------- -------------- - -- DATE_ ` = Alterations and/or recommendations:- -------t-- - �eJ�--.-..--- -.---- -1r�_S_ [�,`��.¢119_-----------.�sL- f s ` a ., ------------------------------------------------ ------------- -------------------------------------------------------I------------------ F€NAL INSPECTION BY = -, -C`-, : Date.........A =' -------------- - ---- tai SAN JOAQUIN LOCAL HEALTH DISTRICT f 1501 E.Haselton Ave. "} 300 West Oak Street 724 Sycamore Street 205 West 9+h Street v S+ocklon,California Lodi, California Manteca,California Tracy,California F.P.C C.