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FOR OFFICE USE: -------- ---------- - ----------- ----------------- -------------- ---------------------- iN .17 APPLICATION FOR SANITATION PERMIT Permto. ---------- -------- (Complete in Duplicate) -• Date Issued ------------- This permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descried This application is made in compliance with County Ordinance No. 549. ---------------------------- JOB ADDRESS AND LOCATTION.----1--G�------------�-`--- �r-+z ''`' ' eul Owner's Name----------ICX-1A----- ---------=------------------------------- ------------------ Phone_! Vt 6J�&-------- I Address Ccvwg- - ----------•-----------------------------------------t------------------••---------•------------------ ------ -----••-----------'--(�- Contractor's Name-----I-'�•---tri. . � - �• Phone.. . ------- ------------------------- Installation will serve: `Residence partment House ❑ Commercial ❑ Trailer Cour ❑ Motel ❑ Other ❑ 11 Number of living units: ___(___l1Numbe of bedrooms _� Number of baths ---A--- Lot size ----VP-'_X---]_.�=._f------------------------------ Water Supply: Public system Community stem ❑ P'rivate ❑ Depth to Water Table __�a ft. Character of soil to a depth of 3 feet: Sand ❑{ . avea.❑ .Sandy y Loam ❑ day Loam ❑ Clay ❑ Adobe 2 Hardpan ❑ t it Previous Application Made: (If yes,date__.._-_---, --__--J 0 New Const+ion: Yes ❑ No FHA/VA: Yes ❑ NoA TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer t available/with n 200 feet.) Septic Tank- Distance from nearest well________________Distance from/foundation__-_________..__-_.Materia4__..----_._._________------___________:____,__.._- ❑ .. Liquid depth--------- ------ ---------Capacity------------=-------•-- No. of compartments_-r=__:__�--._::--=----Size---•-.-----�------------------ 1 . Disposal Field: Distance from nearest well-''N '>^"-Distance/from ounclation-----+S'__`___._-_:Distance to nearest lot line.---,)------------ ` Number of lines--- - - -1- :=----- Length/of,each Ilne--------------L-S--`--------Width of trench.---_•---- -`f- _---------- J ' L jype of filter material----- _ _zme_K_Depth of filter ma gal-------_l length-------_-----------------1�------•---- 6 ' f ------------ Seepage Seepage P Distance to nearest well_ +��"_-_._Distance from foundation_`___-.7_'__.___Distance to nearest lot line___ =__�_____-._ ® � Number of pits---- --�----.`__Lining /material____ . s� _Size: Diameter---}_.;-...---___.Depth----------2 --------------- b f x \ Cesspool: Distance from nearest;wells-_____--_--- __Distance from foundation----_._.___�_.___ Lining material_____________________________________ N ❑ Size: Diamefer� - ° Depth-------------'-•=------ -------- ---------------Liquid Capacity----------------------------gals. Distance from nearest well ___"_____-.____-_:;___--Distance from,nearest building______"__________________________________ t t t Privy: ❑ t s' T �= = _ Distance to nearest'lot line_.`_ ! - f 1 Remodeling and/or repairing (describe): - �`'r 1 ----- --------------- - � -� 1 ------------------------------------------ ---------1-------------------t-------------- ---;------------- �. �j' 1 ------ ------------------------------------- 0 I hereby certify that 1 have prepared this application and that the wor rV1 a done in accordance with San Joaquin County j ordinances, State laws, and rules andfregulations of the San Joaquin Local Health District. y ; k (Signed]____._ i ! t I rt---- (Owner and/or Contractor 1��---- ----------- i T �,!rela�ion -------- -------- - ------ (Plot plan, showing.size of lot, location o system in to wells,.buildings, etc., can be placed on reverse side). r FOR DEPARTMENT USE ONLY ------------------------------------- w : I APPLICATION ACCEPTED BY------- _ .6--- s-- ----------------------------- -----------•---------------- DATE__�4.� REVIEWEDBY-------------------------------------------------- --- - --------------- - DATE / t - -- -a1� DAT ._ 4 ------------------------- AiterDING ations and/or 1 _ •-----�•--� ----------- ---- -- - �� I - --------- ---------- . :. - ----------------- --- � ------------- ------------------ rz :�c-_---- ------ .- . ---- FINAL INSPECTION BY--------- --------------------------------------------------- t4 ----------- Date SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Hazelton Are. 300 West Oak Street 124 Sycamore Street 205 West 9Th Street stocktan,California Lodi,California Manteca,California / Tracy,California Es 9 REVISED B-59 3M 3-'fi3 F.P