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UK OFFICE USE: -3 9C- - ------ --- ------- /. -------------w - --- .___._--..-.--------- APPLICATION FOR SANITATION PERMIT Permit No. .. 1 (Complete in Duplicate) --------------------------------------------------------- / --.--- This Permit Expires 1 Year From Date Issued Date Issued1- 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. 11 JOB ADDRESS AND LO ATION--_---... ........ (r-------------------------------------------------------------------- Owner's Name- - R 'Ro-1-'e -/e�---------------- ----.. Phone-----•------------------ -------------- ------------- ------------- ------- Address ------------ 1a-3k Contractor's Name----------)To ---------/ Phone ------------------------------------- Installation will serve: Residence Apartment House [❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---� Number of bedrooms.__ Number of baths --.1--- Lot sizeZ�-_ ,l-S,-v Water Supply: Public system I10"tommunity system ❑ Private ❑ Depth to Water Table 'Y-ft. Character of soil to a depth of 3 feet: Sand.[] Gravel ❑ Sandy Loam ❑ Clay Loam [] Clay ❑ Adobeardpan ❑ Previous Application Made: (If yes,(date----------- -------`J 9No N'�New Construction: Yes ❑ No RJ/hHA/VA: Yes ❑ No W;--' ` TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation-------------------.Material ---_------- .--.---__..- e Vis,,•- 4) No. of comp artments----------- - ------------Size--------------------------------Liquid depth--------------------------Capacity- ------ I� 4 Dis o al Field: 5 Distance from nearest well_________________Distance from foundation-----------------_Distance to nearest lot line----_-_---__-..- a /,A I Number of lines-1--------------------------------- ines1---------------------------------Length of each line------------------------------Width of trench--------------- ' J Type of filter material-------------------------Depth of filter material----------------- -----Total length----------------- ------ Seepage P- . Distance fo nearest well-------- --------Distance om foundation-_- 4P-Z----Distance to nearest lot line-47/---------- . d Number of pits-- _ � .---Lining material_1� 1_ --fS-.1% --.Size: Diameter_I�-`- N - - -�-- -- ----.Depth-��S"..��•------------- Cesspool: Distance from nearest we]l_.------ ----Distance from foundation--------------------Lining materiaF-- ❑ Size: Diameter---`--- .t Depth --- ---------------------- ---------------------Liquid Capacity -------- ------------.gals. Privy: Distance from nearest well--------- --------------------------------z%mrDistance from nearest a building------------------------- ------ ---------- • ��" ❑ Distance to nearest-lot-line- ------------ ---------------------------------?-------------------------------------------- I ------------- Remodeling ---------- ------------------------------------------ Remodeiing and/or repairing (describe):--.--_-.__---- ------ _ ---------------------------------------------------- ----------------------------------------------------------------------- ----------------------------------------- ------------------=- ---------------------------------------------------------- --------- I hereby certify that I have prepaied flus applicaaf on a d}hate work w t ill_be done`in accordance with San Joaquin County ordinances, State laws, 194rules and rajuiations of the San Joaquin Local Health District. (Owner and/or Contractor (Signed) ------------- -�-- ------ " l.'`I - ---------- ) k _. ------------------------ By:---------------- -- Vii.. Title (Plot plan, showing size of to ce ion of system in relation to wells, buildings, etc., canbeplaced on reverse side). FOR DEPARTMENT USE ONLY r APPLICATION ACCEPTED BY------- DATE- REVIEWED ATE -.... REVIEWED BY . ---}----------------------------------- ----- DATE ' - --------------------------- UILDING PERMIT ISSUED--------------- €- ------------------ ATE----- --------------------- Alterations and/or recommendations-'__'� --�:�---� -:.-_d _ _ =f- , ��.s --------------------------------------------------------- ------------------------- ---------------------------------------- ------ --------------------------------------------------- -------------------------- i t ------------------------------ -------------------- -- ------------------- ------------- ------- ----- ---------------------------------------- --------------------------------------------- FINAL INSPECTION BY:..-- ..... ------- v Date....---3__- SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1401 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street i '40 . Stockton,California Lodi,Cali fornip ti -f - Manteca,California t Tracy,California F.P.C n.