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FOR OFF1� USF,. t ----- fj --- -- ---------- - ---- ----- ---- - - -- Permit No. APPLICATION FOR SANITATION PERMIT _s= I ------ ---------------- --------------------------------- (Complete in Duplicate) Date Issued ___� / -------------------------- 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 descrbed. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATIONS ------ ------- ---- Owner's Name-----,�' �.,KVliT_/:fl �Pf°..�"4� Phone Address -----X e --•---�x±f 'a ' Contractor's Name---- :....-'`�. XG A-- f��l.. Phone................................... Installation will serve:—Residence-[-Apa fr ment House ❑Commercial E] Trailer Court ❑ Motel ❑ Other E]f y .�.,,' syr i. f• Number of living units:`J___ Number of bedrooms 2e-. Number of baths _/--- Lot size _;!Q_ ip--------•-------------------• Water Supply: Public system ❑ Community system El Private Depth to Water Table W. ft. Character of soil to a depth of 3 feet: Sand E] Gravel F] Sandy Loam ElClay Loam Clay C] Adobe C] Hardpan C] 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 frornInearest well_--Q-----`Distancefrom foundation---- Q--------.Materi I_- --1®-_ /1P�----------. No. of compartmentsA---A------_- -----Size----X-- -.--_Liquid;, depth_----- �-`✓---:----Capacity._.F��r--- �. Disposal Field: t Distance from nearest weIL4,O-------Distan of eafrom �- ion4 `�--Widthcofttrenches� t�ine � \ - ---- - p Number of lines- _-_ f 1 9 ` pis ,F--•-------------P - r_ De th of filter maferiaI---/fU _-- ---Total length__-- - � 0-------- , _-Ty' e..cf filter..material 1�+-_ p - �J Seepag it: Distance to nearest-well----- Distance from oundation:--;�.-D__1�_.Distanctyo nearest Int fine_ s Number of pits--------/------- --Lining materiarZZtG .-- ----Size: Diameter-----3 _..-----Depth--- --_-_A'xd~--_-j--__---- Cesspool: Distance from nearest well-----------------Distance from foundation------------------..Lining material.--------------___--_-------------.-. ❑' Size: Diameter--------------------------------------Depth--------------- r'-- ------- ---------------------Liquid Capacity------------------- •------gals . . ! _ ` Privy: Distance from nearest well ___.__--------------------------------•--------Distance from nearest building------------_-_---------_--_------------- ... �� .. . u .i� .4..Yw.. ❑ Distance to nearest to# line------------------ �! '/I(�.- .-. -•----•----•---------------------- Remodeling and/or repairing (describe}---------------�(s'e�lli��_-erf�.e� Lf� �?- -----------------------•--------------------------------'--------------•------------1------------•------------------- -------•------------ = -----• ----------------------- r y -----------------------•---------------------------------------•---------------------- ----------------------------•--=-------------------------------------- - --------------------------- ---------------------------------------------------- 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 regulations of the San Joaquin Local Health District. (Signed) = 's� �� /Y WI -10, =--------------- �r Contractor). B --�.- `" (Title} iJY b { (Plot plan, showing size of lot, location of syste n relation to wells, buildings,etc.-,_can be placed on-reverse side). FOR DEPARTMENT.-PS ONLY- -- - -• APPLICATION ACCEPTED BY --------- ----------------------- DATE Ifs ��f REVIEWEDBY---------------------------------------------------------- --------------------------------------------------------------- ATE_---------------------------------------------------------- BUILDINGPERMIT ISSUED------------------ -•---------------------- ----------------------------------------;f-------------- DATE------------------------------------------------------------- Alt refons and/or recommendations:=-------- = - - ------------------I—------------------------------------------------ ------------------------- ------....-... --------------------- -- `� ------ -- ---- ._. ------------------------------ --------------------- •-------- - - .. ` T- Date ----------------------- FINAL INSPECTION' BY: --- ----- - SAN JOAQUIN LOCAL HEALTH DISTRICT , 130 South American Street 300 West Oak Street, ,i 4! -124 Syca , S`eet 205 West 9th Street Stockton,California Lodi,California Manfeea,California '� Tracy,California ES-9 REVISED 0-39 F.P.DD.SM 6.60 @ ,