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FOR OFFICE,USE I Permit No. .............•• ... . . % C)APPLICATION FOR SANITATION PERMIT / - ----- -- ----------------------------------- (Complete in Duplicate) Data Issued __.. ,1.-��- � ` �" IThis Permit Expires 1 Year From Date Issued ` f 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 N 49. ll JOB ADDRESS AND LOCATION �= ---�---- Owner's Name------------ •-•.• �I - -------------- ------------------------------------------- Phone lr__ - --- -----�h Address---------------------------------•--�-t` f� T --------- --------------- ---- -------------------------- Contractor's Name / •-•--------.Phone-=-------••--•----•...----•------•- r Installation will serve: Residence [�partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 0 r Number of living units: ___.�_ Number of bedrooms -- Number of baths/_____.. Lot size -----------•----------�---- ._. __ Z ---- Water Supply: Public system: Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sand Loam ❑ Clay Loam ❑ Clay ❑ Adobe®/Hardpan ❑ f Previous Application Made: (If yes,dote-----------,--------) No V New Construction: Yes To ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: # (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Ta Distance from nearest well_ istance from foundation__,/.O---------.Material--------�-_____________r-�-C � No. of compartments_-_--_" �►� . `I/ q P ' ----- ----Size----�-�-� --•Q-----Li uid de th------1�--.1='��-----Capac�tY-------- Disposal eld: Distance from nearest well__ istance from foundatior/. �_.�_r___._.Distance to nearest lot line-______________ Number of lines.------f------_______________---Length of each line__-_-----*a-------------Width of trench_____ -- -_�'_____________ Type of filter material__ c1(_______Depth of filter material_ /_k_`/______Total length_____________��._!__ ----------------- \ , Seepage 3 Distance to nearest well__-��___Distance from foundation_/!?___.__-.Distance to nearest lot line_�____�___-_ Number of pits--------)------------Lining material.r__Ya_ _ Size: Diameter---✓_3__.._---__Dept h-------?-------------- Cesspool: Distance from nearest well-----------------Distance from foundation.-------------------Lining material--------------------.---------------- . ❑ Size: Diameter----- ----- ---------------------- ---Depth-------------------------------------------------- Liquid Capacity = gals. h Privy: Distance from nearest well--------------'-+_______________________________Distance from nearest building----------------------------------------- [� Distance to nearest lot line-------------------------------------------------- -----------••-•--------------- ....--------------------------------------------------------- .. Remodelingand/or repairing (describe)-------------------7------>2--a-4 .-----------•---------------------------------- -------•--- ---------------•--•------- --------.-..------------------------------------------------------------------------------------------- -------------------•--•------------------------------------------------------------------------------------ ---------•--------------•---•-----------------------------------•---------- --•-------------------------- ------------------------------------- ---------------•---------------------------------------•------------------•--------------------------- I hereby certify that] have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regu 'ons of the San Joaquin Local Health District. (Signed) - - ----------- ---- --- ---- ----------------------- --------------------------- -----.(Owner and/or Contractor) J� --------- --------------{Tit1eI �reversesi -- --._._...--------- ( Plot plan, showing i of lot, location+ of system in relation to wells, bui , etc., can be placed F 1 / FOR DEPARTMENT USE ONLY / APPLICATION ACCEPTED BY_2,Z/ -- -- - DATE + - REVIEWED BY--------------------------------- -----------//------------------ V� DATE BUILDINGPERMIT ISSUED--------- ------------------------------ ---------------------------------------------- DATE----------------------------------------- -------...---•----- tions: � = - -- - ------------ .. a -- - _- � 1112144c_ ,tel --------------- --------- Alterations and/or recd men w ------------- -----�---- --- - iFINAL INSPECTION BY:-- sl_� ------------- Date-1:Z---./ g G I ---------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street r 300 West Oak Street 124 Sycamore Street 205 West 4th Street Stockton,California Lodi,California Manteca,California Tracy,California I E6-9 REVISED 8.60 F.P.00.2M 6.60 I