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FOR OFFICE USE; --------------- ---------------------------- -------- APPLICATION FOR SANITATION PERMIT Permit No. c -1- ✓ ------ --------------------------------- -------------- (Complete inDu`pRecite) � Date Issued --.-.-- This Permit Expires 1 Year From Date Issued�04'f A 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. JOB ADDRESS AND LOCATION----- il__ __—__ r•_ .u. Owner's Name_e&-A�---- � - �.•ft =-'s ----------------------------- Phone-•---------------------------------- Address---- 5'-1r ------------- -------------------------------•--- ••---- --.......----------------------------------- Contractor's Namez5�,------------------------------- -------••----------------------------------------------------------------- ------------ Phone-------------------------------- Installation will serve: Residence ❑t Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel 0 Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size .---------_..----.-.-_------------------------------------ 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 ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date-----------7--------) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ STYPE -OF"fNSTALLATION AND-SPECIFICATIONS:` (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r Septic Tank: Distance from nearest we4-----------------Distance from foundation--------------------Material---------_------___------------.-_---.-...__--_- ❑ No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- Disposal Field: Distance from nearest we4--------------- -Distance from foundation---------- ---------Distance to nearest lot line----------------- ❑ Number of lines-----------------------------------Length of each line-------------------------.----Width of trench----------------------------------- Type of filter material-------------------------Depth ofJfilter material----.---.-_____._...-Total length------------------------------------------ 6 r g Pit: Distance to nearest well_f --------------Distance from foundation--/P-----_-----.Distance to nearest lot line----tf..-..----.- P 9 ' .-------Size: Diam�t�r -- ----Depth-- -f-------------------------- s- Number of its------- -------- ---- Linin material-- - _._ __ � 6 !,� Cesspool: Distance from nearest well-----------------Distance frWfounclation-------------------_Lining material-.-.--__---__-.__-.---..-.--_.- ❑ Size: Diameter---- ------------- --------.�.-""...Depth__ ------;.---------------- - - -------- ------Liquid Capacify----------------------------gals. Privy: Distance from nearest well.--)------------------------------------�_ _____Distance from nearest building, ❑ Distance to nearest lot line-! ----- - -----F--- -------------------------------------------------------•------------------------------------------------------ Remodeling and/or repairing m'Z ---•------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------- �. --------------------------------------------- --------------------------------------•--------------------------------------------------------------- ------------------------------- ------ ------- - - --------- I hereby certify that 1-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. �St ned 1.;� iD.• .... �r _ ----- �----- ---------= -- - -. - g __.)amu— + ;� � (Owner and/or Gontractorj- B . --- ---' ---- ------ rile S -- ------ -- ------------------------[ )---------- -------- -------------------- ------------------- (Plot plan, showing size oftlot, location-of system in relation to wells, buildings, etc., can be placed on reverse side). .t' FOR DEPAR ENT USE ONLY APPLICATION ACCEPTEDB 6 - -------------------------------------------------------------- DATE. - - ---------- ----------- ----------------- REVIEWEDBY----------------------------------------- - - -------------------------------------------------------------------------------- DATE a BUILDING PERMIT ISSUED-------------- --- --------------------------------------------- ------------------- ----------------- DAZE------- Alterations and/or recommendations:---------------------------------- --------- - ------•-----------------------------------------•------------••----------- --------------------------- ------------- .---- ---- ----- f k .__ - - -- --- . ..... ------------------------- ---------------------------------------- ------- ------ --------------------------------- - ------ --- ------ ` ----------------------------------------------------------------_------ '-�--------------------- ----- ---- ------------------------------- -- ----------------------------- ---- -------------------------------------------------------------------------- ------- - ------------------------------------------------ F INSPECTION BY:. . - -------- Date---N1. -_49 117------------- SAN JOAq..UiN-LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California J Lodi,California Manteca,California Tracy,California