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FOR OFFICE USE: 5-X3 ,r M a 5 kl<iS f 1.4 � _t C, (�a/ APPLICATION FOR SANITATION PERMIT Permit No__ ............. - --- E ------------- (Complete in Duplicate) -------------------- __.._.- _.. This Permit Expires 1 _Year From Date Issued Date issued 1 � 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. A rr — ( } f JOB ADDRESS AND LOCATION---[-_�_`�` 5- -)--`-- c-�,-] -Ri>r5Lt------------� ----------------------------------------------•---------•-- ` j t Phone Owners Name --------------lel+tcZ-1-��=Y------��-±t-{- --------"-Kd-------------- ......... -- , t Address----------•-------- r --- :.... ----------------------------------------------- Contractor's Name s�-3 - Phone---:---- `-------------- ... -------------- - --- -o `er` Installation will serve: Residence E] Apartment House L) Commercial E] Trailer Court [IMotel Elth Oer ❑ 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 ❑- Sandy-Loam ❑- -Clay Loam [IClay ❑ Adobe ❑ Hardpan [] Previous Application Made: (If yes,date__---------- ---t`:)F-No ❑ r,. New Construction: Yes E] No E] FHA/VA: Yes ❑ No Ely.. TYPE OF INSTALLATION AND.5PEC1FICAT{ONS:- �� -� - (Na septic tank or cesspool permitted if public sewer is available within 200 feet.)- Septic Tank: Distance from nearest well---- ---------Distance from foundation-_._t.a---------.Material---- _ ------------ .. ___._._._._-____. Size---------------------------------Li uid de th- Y'-`5 --------Capacityd n No. of compartments---------------�-- a P. ------------- --,-.J-..-�- Disposal Field: 1 Distance from nearest we -------Distance from foundation.. ______....Distance to nearest lot line_..1.�.1--_-. t+� Number of lines------------- ------Length of each line---.------------------------- Width of french------- -•--; ---------------- �'Qiff Type of filter material-----5-R-___-___-____Depth of filter material_______________________Total length------ ____-_---------------.- See age Pit: Distance to nearest well--- .a_-.___,Distance f orr.�foundation_-_ _---____-_.D stance to nearest lot line__J__._._______ '� Number of pits-------�------.._Lining:material----- - ---------Size: Diameter----- - --...._..Depth--------:-t_ ------------------ - Rdld� l o --- ❑ Size: Diameter----------------- --- ----- Depth_�------------------------------------ -------------Liquid Capacity- . ------------------------gals. Privy: Distance from nearest well-------------------------- --------------------Distance from nearest buildi�n-g__ _....____-__..........___.___.____.- ❑ Distance to nearest lot lines--- ---------------�--- ------------------ ------------------------------------ ------------------------- -- -•-------------------- Remodel g and/or r airing (describ Q_ _.,_.Q__ _-. 4_ -o - ---�'l tp/- ---- ------- --- ------ :• '� - '� .�.c' -- ----- ------------------------------------ } ------------------------------------------------------------------------ - -------------------- -__ "----------------------------------------------------------------------------- -------------------- 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. ner.and/or Contractor) (Signed) � '� - •. _ � t _ $�_ - �� BY:--------------------------------------------•-------'------------- - ----------------------- - -----------------------------------(Title) -------- ---- ----- -- ---..- - ---- ~~4C` (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY r APPLICATION ACCEPTED BY--- - - -- -- -- - ------ --- --------=------ ----- DATE_�[3 " - =�� -------------------------- REVIEWEDBY-------------------------------- ---- ----------- -------------------------------------------- DATE-----------=------------- ---------------------------------- BUILDING ---------• -------------•------- BUILDINGPERMIT ISSUED------------------ ---------------------------------------------------------------------------------- DATE--- ---------------------------------------- -------------- Alterations and/or recommendations:--------------------------- -.............. ---..._ 1.'i ----=------------ ------------:-- ------------------------------------ ------ ' � �\ �^��''� &I+ 0 -K_R-d- dUC� --5 TD�'� ° •--------fb----!S-----------Y----- ---------------�L' :--•---T �' ~' ------------------------- ---- ---------------------------------- ------------------------- ----- -----------------------=------------ ------------------------ -------- ------------------------------------------ ----- FINAL INSPECTION BY:_..i{Y---� _'... s� .-------------- --- ------ Date C�- 1 c --------- y --------------------------------- I { SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 6.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CC.