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FOROFFICE USE: ,I�. - " - ----- �, �/ -_____. �.,PPLICATION FOR SANITATION K_.,.MIT Permit No. .../...1. .. •�3 ' (Complete in Duplicate) f ! �----------------- -- _ This Permit Expires 1 Year From Date Issued Date Issued.-•-.J Application is her 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 A OCATION-= ,t ------------- Owner's Name..._ ----------------------------------------•---- Phone.. _s�-_O ». . t ------•-•---------------------------------•-• --- Contractor's Name - .p. /2 --- --•----------------- Phone---- • :.. Installation will serves +Residence ❑ artment House,❑. Commercial'❑.Trailer Court ❑ Motel ❑ Other'�„�,�d {Number of living units: ........ Number of bedrooms -------- Number of baths ........ Lot size __-•________________ Water-Su . Public is stem Communit system Private Depth to Wafer Table __-_---- ft. _ PPIY'.. Y ❑ Y Y ❑ ❑ � Character of sail to a depth of 3 feet: Send ❑ Gravel ❑ Sandy Laam ❑ Clay L•od n ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made; .(If yes,date-----.--------------) No ❑ 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.) Septic Tank Distance from nearest wells _Q_-_4Distance from foundation____!_ ----- Material ►-"'________ ._._� •: . "' No..of compartments___-----_a- ar yip Size- Rt.�.7 - -------Liquid depth_-•--4-'--------------Ca aci . } t Disposal.Fleld: : ..Distance from nearest well_ _ _._ Distance from foundation..../0-_.___•__-Distance to nearest lot (inej2.Q-..... , -Number. of lines------ -- --- Length of each line-----��--- ------------ dth of,french-__ . Type'of filter material.•. Depth of filter material---------4/?! _.Total length-_____r __________---------- Seepage'Pit:' ; Distance to nearest well----------------------Distance from�foundetion�-_._`-----------Distance to nearest lot'line----------------- ❑ Number of pits_--------------------Lining material---------------------.-Size: Diameter-----------------..1Depth.......... -----=-••------. ---•-- `t Cesspool:,, ,.Distance from nearest well----------------- from foundation-------. -----------Lining material............ 4_ .... ❑ Size: Diameter.-------'----------'----------------De th---------------------- ---•- ---- ---------_---- . ---Liquid Caaci ) ------ gals. Privy:a ., ; Distance from nearest well________________________________________________Distance from nearest building "'. ._____ ..........,1 1 Distance to nearest lot'line_r_________________________ '" Remodeling and/or repairing (describe)_________________- - n ' r -----I--------•---- ,, - -4, f ------------------------------------ ' ;r--�--------------•---------•----------•--•--------•-----------------------•-•----------------------------------------------------------•---------- ----------------------------- I hereby certify that I have prepared this application and.+hat the work will be done in accordance with San Joaquin County ordinances, State laws, and rules-and regulations-of the San Joaquin Local Health District. [Signed]_-:_._G�{Cr -�.--•� 'c - -__ ----- ....................[Owner and/or Contractor] By:...................-.........................................----------------------------------.------------------------------------(rifle)_-.----------------------- --------------------- ---------'---- (Plot plan, showing size. of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- r - --------------------------------- -- REVIEWEDBY------------------------------------- •---•---•-------- DATE-------•-----•------•---•------------ BUILDINGPERMIT ISSUED.........-----------------------------------------------•-•----------------------------•----------- DATE------•------••----------------------- ... Alferati ns and/or recommendations--------------------------------• --------------------- ---------------- ------ -----•-•-----____-- f..:.. — tea.-------. � 0-FINAL INSPECTION 'BY:... -_..-._lt,-e.r Date--'---------�5..:. =- �•- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 0-89 YM 6.61 ATLAS