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FOR OFFICE USE: ----------- ---------------------------- - _.---------- APPLICATION FOR SANITATION PERMIT Permit No. __ _1 .......� -- -- ------ -------------------------------------------- (Complete in Duplicate) °'i`/_____ __/� -----------_--------_---_----------------------_--------_ This Permit Expires 1 Year From Date Issued Dat e Issued .._._ v ` Ap'plication 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-_? ___ Owner's Name-- �/ � '1,�p `�F --G'7- ! ap-------- Address r• _� �- Contractor's N e�_ i ' p ; e -6- I li° '•-- �4'-a----- Phone. Installation will serve: Residenc partment House ❑ Com rcial ❑ Frailer Court ❑ Motel ❑ Other ❑ Number of living unif",T Number of bedrooms __Number of baths __/-_- Lot size _ ... -._,� .---__--_..__-_ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Tabl".6—oft.. i Character of soil to a depth of 3 feet: Sand ❑ Gravel [] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [3--Kardpan ❑ Previous Application Made: {If ye s,date....................) No ❑ New Construction: Yes [❑ No Pr` Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic to or cesspool permitted if public sewer is available within 200 feet.) Distance from nearest well------------- ---Distance from foundation--------------------Material _.___.__-_.___.__._.____..___..____.._ _-.-----. No.o7c—o mpart e—fe tts-- --- -- -=--:-.__Size:= ===--------Liquid-d-eptly-------------- Capacity-------------#-------- A M4 Distance from near s} well. istance from fot�nd2tion t > 6-r1D - ------ Distance:itoarest lot line Number hof lines _.___ Length of each fine '____� -� `"��. .'tiN�dth otrench. _ ________�-------- Type _ ._. _� R - �i- Type of filter material __ 6P"filer ater a!_ _. 3__V____.Distan_c . 7ot e�ngth�____ _ __._1S__----.---. Seepa e Pit: pistanceo nearest well _ -pistance om'fondtion___ to nees .lot line---- _.'" 6 Nimberof pits.__[---------. __ �_-.Li g material_ Q ___ ___S e: Diameter __ �` __De ..__ .,_ fj V ` ----- p -c�--7 Cesspool: Distance from nearest ells` ' -____-_.--Distance fro foundation._---.____Lining mate�ic,n ----------------------- ------------------- ------A ❑ Size: Diameter._._. - ____ ------Depths.............. .. -1 ___..Liquic�Capacity I gals Privy: Distance from nearest well - --- *•a Disf nce from nearest building__________ ______________ __.r v ❑ Distance to nearest lot"line ----------- --- ---- -------------M - l ° ------ -- -- ---- ---------- - -----''------•------ ! Remodeling and/or repairing (describe]:_____ ._- -_`____ _ _ __ __-____,_ ------------•----------------------- --------------------- ? - - - ---- -- ---- ------------ :� cr'� a�" -' - _ e 2 P I here4`�ce�tify +Fla+ l�i p"repare�tlf4s ap ca lla+�fhe work will be done` in accordance with San Jo�aqu'tn County ordinances, State laws,,ynd rules and regulations of the San Joaquin Local He th District. ` � pit (Signed)-------------------� -_---_-- �--=_=_=-=--_:�_ .�._. -__�,-:��: ------- ------ ---- - --- ---------- ---------- -------------------- e r ontrac}os] O sEPTIC -r'XNK sl=PIVK5E Y2,915-E.-A4inwx Avo,-'-H4).6%3lL-------------------------------- -- --------------- ------- -------------(Title)-- --------------- ---------------------- ............ --------- (Plot plan, showing size of lot, location of system in relati to wells, buildin etc., can be placed on reverse side). f FOR DEPARTMENT USE ONLY 7i APPLICATION ACCEPTED BY------------------- -- ------------------------------------------------- DATE------ — f REVIEWED BY ----------------------------- DATE BUILDINGPERMIT ISSUED------------- ----- ---------- ---------------------- -------------------------------- ------------- DATE------------------------------ Alterations and/or recommendations:.-------------- -------------- ---------------------------------------------------•----------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------•------------------------•---•------------------------------------------------------ -----•----------------------- ---- ----- --------------------------------------- ---------------------------------------------------- ---------------------- ----------------------------------- ------ --------------------- --------------------------- ------------- ---------------------- ---- ---------------------------------------------------------- ------•----- ---------------------------------- - -------------------------------- FINAL INSPECTION BY:....------ / = d/ - �`� Dat ------------ ........ 40 SAN JOAQUIN LOCAL HEALTH DISTRICT f R 1601 E.Haxellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,Califon Tracy,California