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FUK 101-FICE USE: - r,D ------------------------ -------- _ _______ _________________ r.._. APP�,ICATION FO-R `SANITATION PERMIT Permit No. ..P- _ �'�i� ------------------------------------------ ----- -------- (Complete in Duplicate) --------------- --- This Permit Expires 1 Year From Date Issued Date Issued 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. 3'45'3 .E . e-E^ -r��'r 796J : ,0 3 -- f70-- 2C— JOB ADDRESS AN -LOCATION__ ._ - _- -. ----?-- - Owner's Name �r_L_..l.i�L�%f�LCr{s''-.�i on6----------- Address------ --- ----�--�----------------------------------------------------------------------- Contractor's Name ----------- ---- -------s -----•-••-•--------------- Phone-----•-----•------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other .11 Number of living units: umber of bedrooms Number of baths _7?t'�t size _______________________ _ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft, Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date....................l No [❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: __ (No-septic"tank or cesspool`permitfed'if piibli weris a iav abl wi h 200 fee)k n Septic nk: Distance from nearest well---- ®-`_ Distance from foundation----/�_.___.__.Material---- _x--------------------- t No. of compartment s_._____��_-___.___.Size_ �v�1(_�d`._X__c �_-Li uid de th_____` ..._.______.- ..__Capacity- q p _ 5FO191_ Dispos Field: Distance from nearest well__ ---------Distance from foundation----/D-----------.Distance to nearest lot line_`_((----__--- Number of lines--------'y'------------------Length of each line-------ta0_------------ -Width of +rench_._�c.1-------------- Type of filter material--------5 .Z------Depth of filter material-.--.__If...........Total length---- .2_Q`------------------------- Fra Seepage Pit: Distance to nearest well---------------------- from foundation____-._______--___.Distance to nearest lot line---------------- l ❑ Number of pits--------'-------------Lining material--------------- -------.Size: Diameter-----------------------Depth---.--.------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-----.---------------- __-._______ EJ Size: Diameter --- -----Depth-------------------------------------- -------------Liquid Capacity------------------------- gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building___---------_.________________ El Distance to nearest lot line____________________________________---. i Remodeling and/or repairing (describe):------------------------------ • -----------------------------------------------•---------- -------------------'- r --------- -------------------------------------------------------------------------------- hereby certif at I have prepared this application and that the work will be done in accordance with San Joaquin County I ordinances, State w , nd rules and regulations of the San Joaquin Local Health District, (Signed)--- - -'-----------'-- ---- ---- - -------- and/ Contractor) --- - --------------' -------------'- - -'---'------'-'---- - ------------ ---- - or 00 _ �.,._ . „ BY -- ----- - - --- --------------------- ---------------------- -----(Title)-------= --------------_ _._: :, (Piot plan, showing size of lot, location of system n relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- lt�r� DATE �� + �� 7 ----------------- EVIEWED BY -------------------- ----------------__------------------------------- ---------------------------------- •-------- DATE BUILDING PERMIT ISSUED-------------------------------------------------- ------ DATE ._.- Alterations and/or recommendations:------------------ -------------'--' --------------------•-----------•------------ ----------• ---------------------------------•------•------------------------- ---' '-- ----------- ----------------------------- ----------------------------------------------------------------- -------------------------- r ' FINAL INSPECTION BY:_ Date._. ?."_ . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore street 205 West 91h Street Stockton,California Lodi, California Manteca, California Tracy, California r.RCo. r