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FUROFFICE USE: ------ -- - ------ ------------------- ---------------- -------- -- --------------------------- --________________ _.______._______-__--_-._,_.._.____._ APPLICATION FOR SANITATION PERMIT Permit No. ....�dc��Q` ------------------------------ -- ------------------ (Complete in Duplicate) __---_.__ This Permit Expires 1 Year From Date Issued Da+e 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, Y-�',0 ; (0165'- /300 -0/ #34 !4tL g. c0C.vr JOB ADDRESS ANY' ATION cam,¢ ,-�,u �, - -- *Tti-C � .Se+-Kt,( ,Owner's Nam _ _ ph Address-------7� ----- ---- ----- _ 9W . --- ------------ --------.--------------------- f ----+-- h ---- -r----------------------------- Contractor's Name------ •---••------••--•-•-- ------- --•----- ------ ---— -------- Phone----------------------------------- Installation will serve: Residence teApartment louse ❑ Commercial ❑ Trailer Court Motel ❑ Other ❑ e Number of living units: Number of bedrooms __Number s-baths _J___ Lot size __Z__ -_________________________________ Water Su I . Public s ysterri _ - _. - � pp y' y ❑ ? Community system ❑ Private •Qepth to Water Table __.._ ._ ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam [--IClayLoam F] Clay [Adobe ❑ Hardpan ❑ 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-_____-___-_.._._____- ---------------------------- El ---_-__________:•.______.❑ p ---------------Liquid eP.th-----------------------.--Capacity----------------------- LV No. of compartments .,5V i Dis os old: Distance from nearest well------------ =-=Distance from foundation--- __..--------Distance to nearest lo,line______..._.. N p Number of lines----------- Length of each line------J;___---------------_Width of trench----- _'--__-__:..____._______� t Type of filter material_____. _____+._ ..Depth of filter materia ---------Total length------ ' l-------1-�- -�`_�-_A-------- -- - # ; i ---------- ---- /-- { Seeps Pit: Distance to nearest well-----1_Qa Distance fr = oundation---l__0----___.__ Distance to nearest lot lir�e_..�.___...--.� Number of pits---...--/-----------Lining material_______ P-__-Size: Diameter---3__ja-r------Depth--2.X_____________________-�` > Cesspool: Distance from nearest well-------------__Distance from foundation._- --------Lining inateriaL.____._....__..____.___________.__. ❑ Size: Diameter----------------------------- ---------Depth-------------- - ----------------- -------------Liquid Capacity------------------ - -- --gals. � Privy:-. Distance from nearest well_----------------------------------------------Distance from nearest building---------------_-____________-___..__--- ❑ Distance to nearest lot line----------------- ---------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe)_________ __ __________±__._._ _ � ------ -------------- ---- -------C`_ - - -- ..-.. ---- -----------_ _" ------ --------------------------------------------•-------------•------------------------------------------------------------------9--------------------..-------------------------------------- ----------------------------------------------•----------------------------------•------------------------------------------------------------------------------------------------ ------------------------------ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County w ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)-------------------------- -- ------- --------------- ----0,_ ----- ---- ---------ilidirig,. ------------ ___-_'_ ner and/or Contractor) By:---------------------------------- -----•-------- -- ---- ------ ------------------ -----------------------(Title).------------------ - ---- - --------- -------- --------- `(Plot plan, showing size of lot, location of system in relation to wells, etc., can be placed on reverse.side). + _FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- -------------------------------------- - DATE------- ,----7 -------- ---------------------------- REVIEWEDBY------------------------ ------ -------- ---- -------------- ------------- ------------------------------------ ----- DATE------------------------- --------------------------------- t BUILDING PERMIT ISSUED----- ------------------------- ---------------I------------- ------------------ ------- --- --------- DATE Alterations and/or recommendations:------------------ ------------------ --------- ---------------------------------------------"------------------- y ___________________________"________.________-._--_____..._"____.._.___.____-_--.--_-.__.._________._-."_-____.____.____________________.-...--__.__.__________".____________-________.---__________.________.______..____--_- 'y ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ ti FINAL INSPECTION BY:.-_- �,,c, Date_ .� _��_" A_A�_ w �'�C ---- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CO.