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11 FOR OFFICE USE: I0 616 -- Permit No.l.. �� ------------ --A---�-- --------- ------- APPLICATION FOR SANITATION PERMIT -------- ---- ----- a W {Complete in Duplicate) -------------- - ------_.._-- Date Issued This Permit Expires 1 Year From Date Issued cal Health District for a permit to construct and install the work here-In described. Application is hereby made to the San Joaquin Lo This application is made in compliance with County Ordinance No. 549. ---------------- -•--------------------- Jr-S --------- JOB ADDRESS AND LOCATION-------------------------- ----- ' Ph one-A6 Owner's Name------------- 4_1 --lei6_----------------------------- ----------------- Address------------1___,5__51_.2_._!5f �..... ------------------------------------------ i Contractor's Name__ a/^ - •- �- C- - --- -•-------- •---------- Phone-- �f serve- Residence 'partment House ❑ Commercial L] ' Trailer Court ❑ Motel ❑ Other ❑ Installation will s © f% i --- Lot size _«&9_.x----•'� 'v� Number of bath -�-------------•- E Number of living units: __ _ Number of bedrooms _ _._ s . -Water Supply: Public system 1. ❑Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ , Clay Loam ❑—day ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,dote______________ ____l No F1New Construction E]: Yes No E] FHA/VA: Yes ElNo El 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 frorn-foundation-------------------Material----.------------------------------------------ .. Size------------- =: a--- .Liquid depth--------------------------Capacity----------------------- ❑ No. of compartments F Disposal Field: Distance from nearest well--_-------------Distance from'foundation--------------------Distance to nearest lot line---------------- ❑ Number of lines---------------------------- - ---Length of each line.•"---------------------- Width of trench Type of filter material-------------------------Depth of filter material----.___.--------------Total length------------------------------------------ "p Seepag Pit: Distance to nearest well...__- _.__Distance fro foundation._ --------Distance to nearest lot line__- ----- N Number af-pits~--t.. _-------Lining material._ ----- / '.Size: Diameter- -- -- ---Depth--- ------------------ I. Cesspool: Distance from-nearest well________ _Dis#ante from foundation__.___..____._.-_ Lining materia4..._..._____.__.___.._-_-...__._...__ ❑ gals. Size: Diamete`r----------- - Depth----------------°- ----�s �_�iquid Capacity -------- Privy: Distance from"nearest well--------.-_____---- -------------------------Distance from nearest building._ 1.--------------------------------- --- ❑ Distance to nearest lot line------------ ---- Remodeling and/or repairing (describe):--------. �.--------------`�-------------------- --------------------- u ----------------------------- --------------- -------------------------- ----------------------------•--------------- -------------------------- --------------------- f - -------- ------------- ---" - -- ------ ----------------------------------------'---------------------------------------------------------------------------------------------------------------..-___...___....... I hereby certify that I have prepared this application and.that-the work will be done in accordance with San Joaquin County 1 ordinances, State I&.rysrand rules and regulations of the San Joaquin Local Health District. ---- �N / / �y� �� '-------------- {Q�"nnd/or Contractor) (Signed) �-� . �..p� (Title)------ - BY �- -'-" = =' 1 (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------ REVIEWED BY------------------------------------------- -------------------------- -------- -------------------------------------------- DATE_------------------•-------------------------------------- BUILDING PERMIT ISSUED------------------------------------ -------------------------------------- ------------ - -------- DATE----------------------------------------------------------- --------------------------- Alteraf- ns and/or recommendations:- -"---------------------- ------ -- --•------- '----------------- -------------- --- -- --- --- ----- ---------_------------------------------- ---------------------------- - ---------------- -------------- ---- ---------------------- FINAL INSPECTION BY:---------_-- --------------- - ---------- ------------- Date------- ------ -------------- -------------- ---------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Haxellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California F.F.CU.