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FOR OFFICE: �N (/ _ f� — ---- 11 APPLICATION FOR SANITATION PERMIT Permit No. .� 1 % IM (Complete in Duplicate) - — This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to-[fhe San Joaquin Local Health District for a permit to onstruct and install the wor herein described. This application is made in compliance wi County Ordinance No. 549. JOB ADDRESS ANQOCA IlON Owner's Name- - _ - --------------------------------------------------- Phone _ Address--------- -� f ---40 ---------------------------------------------------------------------------------------- J Contractor's Name ` _ ---------------------------------------------------------------------- Phone Installation will serve: Reside ce Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:!4- Number of bedrooms _AZ_ Number of baths --/--- Lot size -Ae - •--------•-- Water Supply: Public system-1�❑ Community system ❑ Private R-"6epth to Water Table &ft. Character of soil to a depth ofi 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay Adobe ❑ Hardpan ❑ Previous Application Made: 11'f yes,date------__------------) No New Construction: Yes ❑ No 'FHA%VA: Yes ❑ No E�— SII: TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank.or cesspool permitted if public sewer is available within 200 feet.) Septic Tan :r Distance f om nearest well-----------------Distance from foundation------------------- Material-___-_.-------- .-----------.------------.------ /A/1 No. of compartments---------------------------Size--------------------------------Liquid depth------------------------..Capacity----------:-------.--. Dis osal 1=i Id: Distance from nearest well _- - . f Distance from foundation -� Distance to nearest lot line..---.--. Number o lines----_-Z Length of each line--> Width of trench - ----------------------------- . �� ,ii ! 9 Type of filter material�f�,/�E�1 _Depth of filter mater+al..Ile--- _--_.Total length- -- --------- --------- Seepage Pit: Distance to nearest well_,_rA169_____Distance fr m foundationep---..-._--.Dist��a to nearest lot I j e� --_---- I ®� Number of pits___.--/f_----__--Li�ing material_ Size: Diameter p ~---------------------- - i1i Cesspool: Distance fIom nearest well---.-- Distance from foundation------------- ----.Lining material-------------------------------------� El Size: Diameter-------------------------- ----------De th--------------------------------- -------- ----Li urd Capacity all. Privy: Distance f om nearest well._.--'..-.-_______________________---.---.----Distance from nearest building--------------- 0 El �i s Distance to nearest lot line---- Remodeling and/or repairing N(describe)-------------- M I -----------------------------------------------'----M------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------ 1 hereby certify that I have prepared this application and that tate work will be done in accordance with San Joaquin County ordinances, State laws, and r les and regulations of the San Joaquin Local Health District. ► By: AOA (Signed)---------- -------- - `E------ ----- ------------------------------------------- r Contractor) ' --------------- Titie . ---------------- (Plot -- ---------(Plot plan, showing size of lot,if location of system in tion to wells, buildings, etc., can be placed on reverse side). Z ! FOR DEPARTMENT USE ONLY ---- ---------------------------------------- DATE. �� -------------------- ------ APPLICATION ACCEPTED BY-------------- -•�-----.--.----.-.--_-_._._ � REVIEWED BY ------------------ __--------------- --- DATE BUILDING PERMT ISSUED- .- - -------------------- -------------------y-;-----------------------...... DATE------------------ --------------------------- Alterations -------- -------- - , Alterations and/or recommendations --- 1� �- �� k ---- t I ----------- ------------- ---------- --------------------------------------------- - 4-_---- ---------- ---•------ -------------------------------------------- ---- II --------------------------------------------------------------------------------------------------------------------------------------------- ---•--•------------------ ----------------.._.....----- FINAL INSPECTION BY: v-C__ -------- �- �� Date---- .- - -------------------------- I k � { SAN AQUIN LOCAL HEALTH DISTRICT I 1601 E.Hazellon Ave. 300 West 1)ak.Street ` 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.C o.