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�yFl aOFFICE USE: q 1-2 .- -- - ----- - E _ APPLICATION FOR SANITATION PERMIT Permit No. _ _..._.4.. ,ill-ate - (Complete U ` ---------------- ------ Date Issued :: omss ie Year Date Issued This Permit Expires Application is hereby made to the San Joaquin Local Healfh 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 LO �r3 /CATION---- _ a ,C�?__------- �!_.�Z_4 �------------------- Owner's Nam -------• ll/ -- G / - Phone - ----- . . Address--------------010-10----- F� r Contractor's Na .........oeme- l,,t /1 --------------------------- ----------- ----- A---- Phone----•---•---- ... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court E❑ Motel ❑ Other ❑ Number of living units: A-_ Number of bedrooms.._:- Number of baths ,�e__- Lot size � X,- -----`------- --------------------------------- Water Supply: Publics stem f Y ❑ Community system ❑ Private �Deptil to Water Table _�ft. Character of soil to a depth of 3 feet: Sand [❑ Gravel E❑ Sandy Loam ❑ Clay Loam ❑ Clay [j Adobe Z] - ardpan ❑ Previous Application Made: (I#yes,date__________ ______) No MO" New Construction: Yes [;J�'No ❑ FHA/VA: Yes E--`No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest w II_____ '_ __--Distance fro foundation0. _.._/�________.MateriaL_ _ - No. of compartments-. : ___Size_ �` - -1 kX X-AA90'Liquid depth-----*—-------- - Capac,ty-�.�_�p Disposal Field: Distance from n---- well.--- -----Distance from foundation---ZE `__._Distance to nearest lot�/' Number of lines___._:rte----1-----------------Length of each line: 9 � ��------- --------.Width of trench.•`----------------------------- --------Type of filter material/� r ___Depth of filter material___ -__ otal length___ ' ---- Seeps Pit: Distance to nearest well__4QQ.-_ Distance f_ m foundation___ � ---- �pDistance to nearest lot line_?._________ oQ Number of pits----,;&------------Lining material_ Ps--.Size: Diameter_ 9 A _ Depth ------------------- Cesspool: -------------- -Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material___---------------- ___.__________ ---------- ❑ Size: Diameter Depth------------------------------------- -----------Liquid Capacity---.-------------- --- gals. Privy: Distance from nearest well----- _--------._____________ t� _________________-_Distance from nearest building_________.--_._________ ❑ Distance to nearest lot line-----_------------------------------------------------------- --_---- —� Remodeling and/or repairing (describe):_____.__ ----- I --------••------------------------------------•---------•------------------------------------------------------------------------------ --------- -------------- ----------- ---------------------=-------------------------------•---------------------------------------------------------------------------------- ------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 6 ordinances, State laws, and rules and regulations of the San Joaquin-Local Health District. - (Signed)-------------- ----- - --------------- ---- --- •-----------------------------------------------(Owner and/or Co By:--------------------------------------------------------------------- ------------------------{Title)------ d/° Contractor) - - ----------- -- (Plot plan, showing size of lot, location of syste relation to wells, buildings, etc., can be placed on reverse side). t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------_e �------------------- ----------- ---------------------------- DATE--- ------- ---------------- REVIEWED BY. ------------------------------------ ----- DATE BUILDING PERMIT ISSUED_-----------------------------------------------Q_ �----- DATE _ __�_Alterations and/or recommendations:_ - ........ —---- c _- � ------------ - --=--- h ---------------------------- FINAL INSPECTION BY: -- -- ----- - ---------- Date---------------------- �i Y SAN JO QUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California a Lodi,California Manteca,California Tracy,California ES 9 REv15ED 9-59 3M 3-•53 F.P.DD.