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FOR OFFICE USE: --------------------------------------------- ----------- 0 ________._- ______________ APPLICATION FOR SANITATION PERMIT Permit No. _ a - IM----------- ----•------------ -------------------- (Complete in Duplicate) ------------- Date Permit Expires 1 Year From Date Issued Date issued _02__-_ P_-G 7 ealth District for a permit to construct and install the work herein described. Application is hereby made to the San Joaquin Local H Thispplirration.,is.,,mode in compliance with County Ordinance No. 549. � JOB ADDRESS'KNyD�LOCATION_ _ - / t-------- im------------------------------------------------ Owner's Name------- �� 1� / � - -------------------- Address------- _21'r ----- '�� _.. - 3-_ irn------------------------ ----------------------------------•---------------------------- I`. - • I Contractor's Name /5-47—- -----•----•---------------------------- --------------------------------- -------------------------------- Phonel--------------------------------- Installation will serve: Residence In Apartment House ❑]� Commercial ❑ Trailer Court ❑ Motel ❑ l�Other ❑ Number of living units: _1_--- Number of bedrooms _7--__ Number of baths __ Lot size ___ -- - -________________________________._ Water Supply: Public system ❑ Community system ❑ Private [y]] Depth to Water Table a_O ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam U Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ -I Previous Application Made: {If es,date____________________) No New Construction: Yes Na PP Y ❑ ❑ ❑ FHA/VA: Yes ❑ No ❑ { TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r,. } Septic Tank: Disfance from nearest well_________________Distance from founddtion--------------------Material__.._______._.;--._---_-__.________._._� ryl � ❑ No. of compartments-------------- ----- ----Size------------------------- Liquid depth- - ._Capacity Disposal Field: Distance from nearest�weli__1:......Distannce�fr n foundation___�_�/..____Distance to nearest lot line_ r____._.--�C• ] Number of lines__�� `" -s__ -----Length of each €ine_.__.�_W_�?----____-------Width of trench11.X4-__---__-_--________i , Y Type of filter maferial-_�_- ___._______,_.Depth_Rf�filter material______l�_________._.Total length----1__t4-______..___________________ Seepage Pit: Distance to nearet well_.___.__ _ foundation*'-,-!______.___ Distance to nearl[st lot line____.__-_-.____ __._.______Distance from � ❑ Number of pit : - -------------Lining material-----------------------Size: Diameter-- -------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation_11__ - ._.Lining material---l--- -- - ------------------•- P ---------Liquid Capacity---------------------------gals. . - IM ❑ Size: Diameter.------ ------------------------------De Depth -- �------------------- - - Privy: Distance from nearest well_________________________________________________Distance from nearest building - ; 1 ❑ -- - - .� . .. .,., ,,w.,�., Distance to nearest lot line - - -- -- - - ------- ---- =------------------------------I r Remodeling and/or repairing (describe):-------------------- ------------------------------------------------------------•-•----------•--------------------=1'------------------------------- lM------------------------ ------ . _I ----------------------------------------------------------------------------------------------•--•---- ---------------------------------------------------------------- -------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 1� ' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, State laws, and rules and regulations of the San Joaquin Local Health District, f (Signed)---------- /1�-"' '� ----t — -- --------- _e`----- ------------------------------------(Owner))and/or Contractor) I BY ------------- - ------------------------------------------------------------ -(Title)------------------ --------- .- -------- ------- (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_°-'_-/_7 -------------------------------------------------- ----------- REVIEWED BY-------------------- ------------"--------------------------- DATE-------------------------�M r BUILDINGPERMIT ISSUED--------------------------------------------------------------_------ ------- - ---------------- DATE----------------------- I Alterationsand/or recommendations----------- ----------- ----------- ------------------------------------------------•-----------------------------------•----- ----- ------------•-------------- II. II I ------------------------- -------- FINAL INSPECTION BY:_.. -- --- ---- �--- - -------- --- Date, - 'C -- -- - -- ------------------- n �e. SAN JOAQUIN LOCAL HEALTH DISTRICT 1b01 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi, California.-- Manteca,California Tracy,California F.P.C n. .