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FOR OFFICE USE: GY---- -------------------- --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. - -'---- (Complete in Duplicate) I Date Issued _________________________ ___ _ _ L This Permit Expires 1 Year From Date Issued k 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. 5 9. JOB ADDRESS AND LOCATION----_�. -------- �------ ---------------------------------------------------------------------------------------- -t Owner's .Name ____ -------------- __ Crt?!Q_ _ Phone------------------------------------ Address------- «LAa-- ! ------------------_---•-------- ----------------------- -----------•---•-- •-------------------.....-----------•--------------•-•------- Contractor's Name - -TSM-M M-MM-M -------------------- Phone------_--_------------------------ Installation will serve: Residence Plr Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___I___ Number of bedrooms _q___ Number of baths -1----- Lot`size ---lx__� _ I 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 0 Clay Loam ❑ Clay ❑ Adobe [Hardpan ❑ Previous Application Made: (If yes,date____________________) No-IT" New Construction: Yes Pr No ❑ FHA/VA: Yes ❑ No r TYPE OF INSTALLATION AND iSPECIFICATIONS- (No septic tank or cesspool permitted if public sewer is available within 200 feet.) s. Septic Tank: Distance from nearest well_-_'�'..------Distance fZm foundation__!1'-_____________Material_ _..._ __...................... I � r� No. of compartments - ---------------- - Size---`'ryy--------x---cl------I-----Liquid depth--------------------------Capacity--- ��-'-�-- � r Disposal Field: Distance from nearest well----.'-__._._._Distance from foundation./_...------------Distance to nearest lot line--107�e__ 7__.__... Lil Number of lines___-__�:__ _________________Length of each line_1_Qo"_.8'P____._____.Width of trench.___ _1 _______..______.__ Type of filter material__ dC_�__._ -- of filter materia!---1_$'---------------Total length---.___I jp_--______________________ I Seepage Pit: Distance to nearest we!!___.!r ----------Distance from foundation---'p---------_Distance to nearest lot line__�------ �1 Number of pits___.�._._..______Lining materia f .___.__.Size: Diameter__Z'_'.'---------Depth___Z_-5--_'_____________ to i Cesspool: Distance from nearest welL________________Distance from foundation--------------------Lining material__._.__._.____.._..._._____________.. 1 ❑ Size: Diameter- ------r-------- - ------ ---- -- Depth ------- ---------- ------------ Liquid Capacity---------------------------gals. Privy: Distance from nearest well_-----------___.___---------------------------Distance from nearest building..------------ ------.___________._____- ' k ❑ Distance to nearest lot line------------------------ - --------- --------- ------------------•---------------------------------------------------------------------------- I Remodeling and/or repairing (describe}--------------------------------------------------------------------------------------=---------- ------------ -------------------------------- c� r --------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------- -------------------------------------CX ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- "ggam ----------------------------------- --------------------=----•-----------------------------•-••------------------------------------------------------------------------------------ - ------------ ------------ ------------ 1 - ------1 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. Si ned ( g )________________________ __________4..__ _ _ _ (Owner and/or Contractor) --- ------------ By---------------- •= -• -----------•--•---•-•------------------------------ ----------- (Title)_ (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 APPLICATION ACCEPTED BY ---------------------------------------------------------- DATE---/2-T-q- 7" REVIEWEDBY----------------------- -------------------------------------------- DATE------------ ---- --------------------- I BUILDING PERMIT ISSUED---------------------------------------------------------------------------------- DATE---------------------------------------------------------- Alterations and/or recommendations:--/�2.~3~--Ga�------. ------------•-•--------------•-------------...----------------------------- ------- — � FINAL INSPECTION BY: p Date_ ------ --- FINAL 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.C C.