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I � FOR OFFICE LISE: -- --------- 5-5_4 F--------------------- Permit No. ..r_ 1� APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Date issued --- ------ ....... ` This Permit Expires 1 Year From Date Issue ! 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 'n compliance with County Ordinance No. 549. �y ��: 2�S�a� -`ES� � CP�}� � fTi' r X13 S� rt-✓�/—e�- S/DEavv JOB ADDRESS AND L ATION CARRC?L Crr Owner's Nam "_ __ ^� Phone "� ;AFr_ -R--------- ----------- -- Address ' ---_-----e4---`---------------------- - hone ...- ' Contractor's Name--- ---------------------------------------------------------- InstaP i Ilation-will serve: Residence [Apartment House ❑ Commercial 0 Trailer Court ❑ Motel ❑ Other ❑ ---------------- Numberof living units: _ ____ Number of bedrooms 3)_- Number of baths ,,S"-- Lot size -- . tieaF =- Water Supply: Public system ❑ Community system '❑ Privateka-`Depth to Water Table 2:T_ ft. Character of soil to a depth of 3 feet: Sand Gravel❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date.---_.---.------_.) NoNew Construction: Yes El No �HA/VA: Yes El No TYPE OF INSTALLATION AND SPECIFICATIONS: No se tic tank.or cesspool ermit+edTif ublic sewer.is available"wi+hin...200,fee+_] Septic nk: Distance from nearest well------------ ---Distance from foundation-------------------Material"--------------------_ _--_---" ---..---__-. MlSi-lNE#to.-of compartments-------------------------size------------------------------,.Liquid depth ------ --------------Capacity------------------------ Disposal Field: Distance from nearest well...-.-----Distance from foundation. --,��---."__-.Distance to nearest lot line__-"" ti _;-- - /� Number of lines4---------I ----Length of each line------- ----------Width of trench... 2-t- ----------- t ------------� rial-.".. _ -----------Total lengthoType f filter material---� _-- epo Seepage Pit: Distance to nearest well_ ------_-- Distan e to nearest lot lin ------------ e_,____ r --------- _-_�[�.""""_Distance from foundation ------.Depth----------- Number of pits_;____�___---"__Lining material-}��!�a___--"-Size: Diameter__ .- --"-_ Cesspool: Distance from nearest well--.------------------Distance' from�ffoundation---------------------Lining material-. ..--..--_-----.-..-_-----_ ❑ Size: Diameter-------------- ------------- - ----Depth_---------------------------- ---------------------Liquid Capacity----------------------------gals. r Privy: Distance from nearest well---------------------------------------- ----"-Distance from nearest building.--._.-.--.---_- -----------_-.___---. ❑ Distance to nearest lot line ------------------------------ -------------- ------------------"--- ------------------"---------------------------------------------- - =- = Remode4ing and/or repairing (describe):------ ------------ --"---•---•-------------------•--------------------------------------- -- --------------------- -- ---------- -------------- ' -""--•-----"-------------------------------•--------------- ---------------------------- -------------------------------- I hereby certify that I haveprepared this application and that the workwillbe done in accordance with San Joaquin County p r ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. Contractor) (Signed)927A&.1. .� - -- --- --- _ = (Owner and/or n tor) _ ------------ T -- ---- ----- - ---- ----- ------ ---- -(Title-------------------------------- - ------- - ---- -- C plan, showing-si of lot, Inca+Ion of system'in relation to wells;buildin`s, etc.,can be laced on reverse FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY". I ' �, '----- ----------- DATE-------� C `� ----- ---------- - ----------------------- REVIEWEDBY-----------------------__------ - -------------------------------------- ------- -------------------------------------- DATE------------------------------- --------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------- --------------- DATE------------------------------------ ---------------------- Alterations and/or recommendations-----------------y----- ----------•--------------•------"-------"-------------------------- .......... - ------------- ----- I----------I ....... --------------R --------------------------------- ------------------- -------------------- FINAL INSPECTI�1tt�,. Date------- � -----'--6' ---------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.co.