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FOR of ICE E: '� --------=- •�� J 3 APPLICATION FOR SANITATION PERMIT Permit No. _..1.. .... {Complete in Duplicate) 3 ,. Date Issued ---.....1 w4l�,l. ----------------______--------------------------- 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 described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION---/, •,r, __ C�.W p9t� --------------. '.......... ------------------------------------- ........ Owner's Owner's Name '� G-�.� � I � -------- - ---------- --- Phone'� Address �/... ---- 4?.� 1?7t1� 1 --------------------•---------------------------_--------------•------------------------..------------------------•_... Contractor's --------------------------------------------- Phonez/e--- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms ___Number of baths ._ __ Lot size .... .-x---.l -de-------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay :Loam ❑ Clay ❑ Adobeg Hardpan ❑ ~ Previous Application Made: {If yes,date.----------,-------1 No d New Construction: Yes ❑ No FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) tic Distance 'from nearest well_________________Distance from foundation_--__.--------------Material No. of compartments-------------------------- Size.-........ ---------------Liquid depth--------------------------Capacity:------------- { Disposal Field: Distance from nearest Distance from foundation-__=_/ -Distance to nearest lot line___ r�T. ,� Length of each line._ - ------,Width,of,trench.----- --- ••------------•--- Typebof filter material _. Depth of filter material__::/S-"`---_-Total"length''________________yl_- Seepage Pit: Distance to nearest well_kkoma-------Distance from foundation___/...___.Distance to nearest lot line----------------- Number of pits--_-�______________Lining material...L�'�-----_.Size: Diameter---3,311--------Depth----- 7-'_____.___.___- Cesspool: Distance from nearest well____________..Distance from foundation---_----------------Lining material__------____--._______________--._-_. I Size: Diameter-------- ----------------r ----------Depth----------------------•----------------------------Liquid Capacity----------------------------gals, Priv Distance from nearest well------..--------.---------------------------------Distance from nearest building______--____-________________..__-____..- (moi Distanceto nearest lot line.-.- ---- -----•----------------------------- ------------------------ --------------------------------------•--•------------------------- Remodeling and/or repairing (describe): , ----- -------•----- ---------------•--------------•--- f-*M ---------------------------------••---- --- -- --- ----- --------- --- � . --..------------...-------------- -------------------------- ------------•-------------------.----------------...--... ---------------- -------------------------- ----------=---------------------------------------- ------------------------------------------------------------------------------------------------------------------- I I hereby certify that I have prepared this application and that the work will be`done in accordance with San Joaquin County ordinances, State laws, and rul s and regulations of the San Joaquin Local Health District. _ (Signe d]_.r+«_CSI 11 i �1, `�'1rcT_• ------ - --- ------ Contractor) BY: `-----------------• ---------------- (Title) ------------------------------------------ I (Plotplan, showing size of lot, location of system in rel n to wells, b 'dings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----� s.-- . xtJ -----------------------+ -� ----- DATE-----�-'�=r�------��-------• --` - -- - REVIEWEDBY---------------------------------------------- ------------------ ------------------------------------------------------------ DATE----------------------------------------------------------- BUILbINGPERMIT ISSUED-----------------------------=------------------------------------------------------------------------ DATE--------------------------------------------------------------- Alterationsand/or recommendations--------------- I--------=------------ - - ---------•---•--- ---------...--•-----------------------•---•--------- ---------------------------------------------- 4.Z --------------•------------------------------ w -Z-------- ---- /� ------------- i ` FINAL INSPECTION C ----- ------------ Date----------- -- 11----- r ----------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 134 Sycamore Street 205 West 9th Street i Stockton,California Locil,California Manteca,California Tracy,California E6.9 REv19EO 0.59 F.PX0,$M 6.60 I ., v