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FOR OFFICE SE: r " + w ,M �; & P--- ,t - _________________ APPLICATION g'FOR SANITATION PERM 7 Permit No. . / !� --------------------------- ---------------- ------------ (Ccrnplefe in Duplicate) � - ----------------------------------------- ------ --- This Permit Ex- fres i 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 Orpinance No. 54,9.. JOB ADDRESS AND LOCA �.. '= ION__ Owner's Name - Phone"---------j "----- ------------- •----""-------------.-"-------- -----..._. Address--------- -• - . ..........-••-•-. ----•----- -----••--•----•----•.....---•--•....__. ---- Lk 4,Name....... Ln-& O� ` _....... . . _..._.. Phone _. Q Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑` Other ❑ I Number of living units: 1______ Number of bedrooms __ __- Number of baths ___ Lot size ------_-- -0--------�...... ------ Water Supply: Public system 'XCommunity system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 lteef: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe (" Hardpan ❑ Previous Application Made: (If yes, l__) No [I New Construction: Yes E] No �FHA/VA: Yes [INoX TYPE OF INSTALLATION AND SPECIPI TTOf<S. (No septic tank or cesspool permitted if public sewer is available within 200 feet.) '` • - (�/!,, Septic Tank: Distance from nearest well----- ------Distance from foundation-___--LQ-------Mat ri 1... -_- r'�'�� No. of compartments___-1-�_ _--Size....._ __ .. (Liquid degp h______ ____________..Capacity.......-.�}- Disposal Field: Distance from nearest well_______ _____Distance from foundation..... 1 _._ _ _-___.Distance to nearest lot Number of lines....._____��____ Length of each line------- Width of trench.___.. � T e of filter-material._ �r C yp __ ___Depth of filter material_, .._--•-••----Total length_._.._._.._.. --__._-------_. --.-.----- W Seepage Pi kr (Distance to nearest well_______________------Distance from foundation____•_•_-____._.•__.Distance to nearest lot line_.............. ❑ Number of pits----------------------Lining material- :--------- Size:•Diameter-----------------------Depth-------------.................... Cesspool: Distance from nearest well-----------------Distance from foukndation.__.----------------Lining material_______...__._._____.__________-•---- �n �,❑ Size: Diameter--------------------------------------Depth----------------`-- ------Liquid Capacity------------_---------••-_gals. V Privy- Distance from nearest well __________________________________-------------Distance from nearest building___________.--_.___.._________.__._______- vj ❑ Distance to nearest lot line------------ •--•---------------------------------•-•..._._......---- y r Remodeling and/or repairing (des,ribe}:------�- /1= �1,___-- �- ,,___ .-- -•.. - ................ I •• _'` -- . ------ = :..: :: �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 rules and regylations of the San Joaquin•Local Health Disfricf. (Signed).....--....... -----`--- --------------•-------------------------(Owner and/or Contractor) By:• -•-••------------•-•-•---••--•---•--•-------....•-•-•.-••-----------------------------------------------------------------------(Title)..-------------------------------------------------------------- (Plot pla , sho ng size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICA ON ACCEPTED BY------------- --- -----------------------------REVIEWED BY----------------------------------------------- .----•---- ------------------•-----------------• DATE BUILDINGPERMIT ISSUED--------------------------------------------- -----------------------------------=----------------- DATE---•-------------------------------..... Alterationsand/or recommendations--------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------- -------....----------------------------------------------------------- .............................................. I FINAL INSPECTION BY--------------- - -----• ------:� ,-�. ------------ Date------------------Z. --------------- -------------- 4- 5 .K SAN JOAQUIN LOCAL HEALTH DISTRICT . 130 South American Strut 300 Woof Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,CaliforniaManteca,California Tracy,California rG 9 HEVISEP 8.89 PM 8-61 ATLAS