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—��-. _______________________ APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) t +�-----------------4-1 _ This Permit Ex ices 1 Year From Date Issued Date Issued ___ I 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. J013 ADDRESS AND LOCATION ---- 7-----__` � Owner's,Name S - ------------------------------------ Phong -------- Address...- ---- ddress--• f * ------------ Contractor's - --•------------------------------- Phon ....__� Contractor's Name_____ _ c_{ � I Installation will serve: Residence Apartment House ❑. Commercial ❑ Trailer Court [] Motel ❑ Other ❑ Number of livingits: unNumber of bedrooms a .. Number of baths __l.._ Lofi size ._ _ _ - -l S�d i Water Supply: Public system �` Communitysystem W { y [� �Priva+e ❑ Depth to Water Table f#. Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [I Adobe Hardpan [J7Previous Application Made: (If yes,date--------------------) No ❑ New Construction; Yes ❑ No,M FHA/VA: Yes ❑ No ❑" TYPE OF INSTALLATION AND SPECIFICATIONS: � (No septic tank or cesspool permitted if,public sewer,is available wi+hin 200 feet.) OD;sp'sal tc Tank: Distance from nearest well___- -____Distance from foundation___________________.Material-___ ___________________,_�, L L ________________me f' d: Distance froNo. of pm ne'ar'f - well -.Distance '°" '"------ -- Liquid depth--------=------------------Capacity--------------------- - � - - stance from foundation.___/4�.-__-.Distance to nearest lot line___. �___..' Number of lines-------- _____ _ Len th of each line_---_• _Q__--f�-•_----_- _ �-H Length -- � Width of trench._�_�.---...... ----._-----•_-�: Type of filter material- ---_pepth of filter material-- e length___�' ____ Q ,. , 5eepa it: Distance to nearest well- ---Distance from oundation__-4___Q-___----.Distance to nearest lot fine...... -y Number of pits-- _______Lining material `r Sixe: Diameter_-3 Depth__ -5 -------•-----•--- Cesspool: D;Sfance from _____.__- nearest well__-_ ---7 Distance from foundation__________._:____lining material.________________________________ r ❑ Size: Diameter-------4 I --;-r----_-------.-A. --------.Depth-------1-t.------- --- ---------=----------- ------------=Liquid�Ca pacify -----------•--------------gals. Privy:r Distance from nearest well___________________________ ______k_____________Distance fro nearest building:____.___.----------------------------- ----------- _- . ..... .I° - - - ❑ Distance to nearest lot line--------------- ------------------- # Remodeling and/or repairing (describe)___________________ t # ---------------- -------------- ----------- ••-• ------ •-•------------------ -- - ---------------------------------- �:. _ -� --------------------------------------- • -- --- - ------------------ ------------- -------------------------•---------------------------------------------------------------------- - --------------------------------•------------------------ I hereby certify that 1?have p- repared this applic'atio'n and that +he work will be done in accordance with San Joaquin County a ordinances, Sta aws, and rules and regulations-of the San Joaquin Local Health District, � p w 1 = (Signed)•------• -----------=------ (Owner and/or Contractor) q By:---------------- = 'i= ' ` k ---1 --- --------------•-------------•---------(Title)---------- r-------- --------------------- -- (Piot plan, showing size of lot, location of system �inrelafi o. ells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY____. ----- - - --------- ---7------•------------------•-------------- DATE----lEWED BY - -------------- � �/ .---------------------- --------------- --------------------- --------------------------------�----------°- ---------------------- ---.. DATEBUILDING PERMIT ISSUED_..'--------------- ------------------------ _ ------------•------•--------- ='- ------------------------ ------------- ----------------------- ----------------------- -------- DATE--------- Alterations and/or recommendations � _> ----------------- --------------------•----------•----- -- -------------------- = ---------------------------------------------------•------•------- -----`---` =!=-- - rf l� --- - -- ---- --------------- --- ------- -------•---------------------------• -------- , .. a . ------------ -------------------------------••------------------------------------- FINAL INSPECTIO `BY - = ---�'�'� Y "" _ ." "". Y _ . . T_ . -• =-.. '- -- - ---- ----------��- ----•---- Date------- N . SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street } 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California r EB-9 REVl5Et]e•59 F.P,C O.2N 6•60