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FOR OFFICE USE: i ----------- -----------'-5a--- _______________ _____._-- APPLICATION EC1R SANITATION PERMIT Permit No. E _.: -.(Complete in Duplicate) This Permit Ex fres 1 Year From Date Issued Date Issued ----------------------- -- Application is hereby made to the 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 AND -'C TION a 7� { � . . � __ ' ---- ---- -------------- ---------------- - �`p� Owner's Name - ------------ Pho Address-------------•-•........I ••-----.- ------------------------------------------------- Contractor's -------------- Contraetor's Name- ------•--- -'-- ------- ------ Phone... Installation will serve: 'Residence/�partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __-!._-- Number of bedrooms __77:1N umber.of baths _"- "" Lot size .___ Wafer Supply: Public system.. Community system ❑ Private ❑ Depth to Water Table .(L2 :�ft. t Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe,®-5ardpan ❑ 1 - Previous Application Made: (If yes,date.------------------- No ❑ New Construction: Yes ❑ No Z_--F9A/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S is Ta f Distance from nearest well-- _---"-_-___:Distance from foundation____"-"___--------.Material-._""""_-___"._..-.------"______________"-__-___. No. of compartments--------------------------Size------•-------------------------Liquid depth----------- --------------Capacity----------------------- Disposal Field.: Distance from nest we l!_qObistance from foundation""" __.Distance to nearest lot line._""-• Number of lines_._,__-- .-, _ -"-- Length of each line__-_ " Width of french...... Type of filter materia. __ _ y� - i/ i Yp + � _Depth of filter matenal_C ____-_ _Total length"__--1k __""_____"""_ Seepage Pi Distance to nearest well ; .0 """Distance from foundation__rt. _-_"".Distance to nearest lot line-- A +� Number of pits.--_-# __.____- _Lining material_,-----------Size: DiameterfrC ___-"""-_.Depth-_ ,, ��-S- Cesspool: Distance from nearest well_________________Distance from foundation___._____-_--_.-----Lining material---------------------------_._____-_. ❑ Size: Diameter------t---------------------------- - Death-----------------------------------------------------Liquid Capacity----------------- --------.gals. a . Privy:. Distance from.nearest well"___.-_"""__.__-----------.---"--------__-__"_:Distance ,from nearest building ❑ Distance to nearest lot line--------------------- m Remodeling and/or repairing (describe):----------------------------- - ----- ------•--- -- - ------------ ------------ ti --------------------------------------------------------------� 00 -----•--------•------------ -------- -- ,�c-.!e�.�..---------------------------------------------------------- t; ,_ ---------------------------------------------- -- - ------------------------------------------------------- ------------------------------------ -------------- I hereby certify that I have prepared this application and than the work will be done in accordance with San Joaquin County ordinances, St to laws and rules and regulations of the San J Local Health District. Si ned _"" _ ' { By: -------------------":----- -------- -------------------------------- ----- - ---------------- ------V __4, (Title) ----------- --------- --------..... ........... (Plot plan, showing size of.lot, loca+ion of system in relation t wells, buildin s, to can be laced on reverse side). } g p FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED. BY...... y BATE 2—` �� ------------------ REVIEWED BY.- --------------------------i------------ --- DATE------- - --------------- - ---------------- •------------------- •-- BUILDING PERMIT ISSUED----- --- --------------:-------------------------------•------ =-------------------------- ----- DATE------------------- Alterations and/or recommendafions----------------------- ------------ ------------- -------------------- --- - ------ - -- ------------------ 1------------------ - ----------------- -- - ------------------------------------- -- — /_ . 4_- ----------------- ---------------- -- ---- --------- - ---- ----------------------- -------------- ------ -- -- --- -- f - ---- ---------- --- ------ FINAL INSPECTION BY:---------j.----- Date----------------------- -- . `_ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Mazatlan Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California Err. 9 REVISED B-59 3M 3"•63 F.P.Ca.