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-FOR OFFICE USE- -------- --------------- ----------- APPLICATION FOR SANITATION PERMIT Permit No. --------------------------------------------------------- (Complete in Duplicate) Date issued ------------------------------------ --- --------------- This Permit Expires 1 Year From 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. s, - - - . ------------- : JOB ADDRESS A L CAT10N_ ;�_7___ m. .YiP _ ` - --- --------- ----------- ---- -- - - ---------- ----- --- Phone.---------.------------------------- Owner's Name--------- - -••---------------E- - 4 AZP Address----------•--------- --- -�----------"-- -------- ----------------•...---- I Contractor's Name - --------------- Phone-------- -------------------------- -• ---------- Installation will serve: Residence Apartment ouse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. ___./_ Number of bedrooms _1 Number o baths I--- Lot size ---------------------'__________-__-________________.-__.._ Water Supply: Public system ❑ Community system ❑ Private pth to ater Table -------- ft, Character of soil to a depth of 3 feet: Sand ❑ Gravel [] Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ I P Previous Application Made: (If yes,date._-.-_..`----------.._) No ❑ New Construction: Yes ❑, No ❑ FHA/VA: Yes ❑ No ❑ 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 ..___.._____.____-.--.___________.__...._____- ❑ No. of compartments---------------------� Size--------------------------------Liquid depth----------- --------------Capacity---------------------- I Dispos Field: Distance from nearest well---4 ._I--Distance from foundation-----1_p__------Distance to nearest lot�ine----�___..... P��H Number of lines----------- --------- ---=----Length of each line---------0_0. __._______.Width of trench---.�-------------------------. - �, - < r r Type of filter matenal_________.i________ ___-Depth of filter matenal.__.__l ___.__dotal length___... 1�_____________________________ F �`® � r Dis#ante to nearest we _ _________.......Distance fro foundation___-____t�___--.Distanc`e to.nearest lot line__-X-_________ G Number of pits ----------/- ------ Lining material--------- Size: � Dep th----!2---- --- El -� r Liquid g p •. y Cesspool: Distance from nearest well_____________�_-Distance from foundation.-------------------Linin matena------------------------------------- Size: _._.___._._-______._______.__._ _ __ ❑ Distance from nearest well-----------' WDepth----- -------------- ---------- -Distance from nearestbuilding i -----�. ------------------- gals. + Privy: I ❑ Distance to nearest lot line---------- ----- ----------------------------------------- --------------------------------------------- -•__________ _ _ ___________ __________ _________________________--.___._________________�1 Remodeling and/or repairing (describe):----------------------------------------------------------------------------------------------------------------------------------------------------------- __ ---______._____________- _____ a ___ ------ ---------------------------------------- _1____------------------------------------------------ ---------------------------- ---- ------ --------------------------------------------------------------------------------------------------------------------------------------------•-------------------------------- y I hereby certify I have prepared this application and that the work will be done in accordance with San Joaquin Count I ordinances, State ws, a rules and re tions of,the San Joaquin Local Health District. Si ned --------- ------------------------------------------------ n r Contractor) BY---------- - ---- ---- ----- ----------- ---_-------------------------------------- (Title) -- - -------------r--a------o ...----------- i (Plot plan, showing siie of lot, location of syst m in relat n to wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- { ___ DATE___ _.._ G REVIEWEDBY------------------------------------------------ ------------- ----------------- -------------------------------- DATE----------------- -------------------------------------- aBUILDING PERMIT ISSUED------------------------------------------------------ -------------------------------------------- DATE--------- -------------------------------- -- -----`------- Alterations and/or recommendations--- ------------------- ------- ------------------------------------------------------------------------------•------------------------•------- -------------------------------------------------------------------------------------------- ---------------------------------- ------------------------------------------------------------------------ ------------------- - r 3 Date �� k-------------------------------------- FINAL INSPECTION BY __ .. ------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.0 C.