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FOR OFFICE USE: �l - --------------- --------- ---------- ------ /6- ---------------- ------ ----------- ------ -- .E APPLICATION FOR SANITATION PERMIT Permit No. . .............. 'i Com lete•in Duplicate) _ _...______....__--_. . _ .._A I This Permit Expires 1 Year From Date Issued (f"' Date Issued Application is hereby made to7the 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 LOC TO �--- ` ---------•------------ � ------------------ Phone------------------------------------ Owner's Name- -------------- --------------------------------------------------- Address - .-®-- ' - .... -----4-------------------------------..-..--------•---------------------- �l ContractorsName-------------•----=`---•--•-------------------••-• ----------------------------------- - ----• ---------------------------- ------------------ Phone----------------------------------- Installation -----...-----------•-------- -----Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:`'-_- Number of bedrooms ___ Number of baths-----1. Lot size -----0VU',-0-_kk1----_._----------------------- Water Supply: Public system�!`❑ Community system ❑ Private ❑ Depth to Wafter Tabled a_ ft Character of soil to a depth of 3 feet- Sand ❑ Gravel ❑ Sandy Loam`-9 Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date_-------.--------._ ) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ 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 from foundation--------------------Material ------------------------------------------------ ❑ No. of compartments--------------------------Size-------------------- ----- -----Liquid depth------ ----- --------Capacity...--- ---------------- 4 ' p iom nearest well... Distance from fouridation__ft!--.------_.Distance to nearest lot Disposal Field: Distance from -----.Width of trench._`2~_` ______________ Number of lines-----------_I------..-._._ ------Length of each line------_�eI'______._..._ Type of filter materiai.__.,6,1R.-..._._._ --Depth of filter material-----_�Q_K__------.Total length-----(0 ------------------------------- C��wli , rt. {�,'umabere of nearest well..`S._.0.�___.._...Distance from oundation._.'.1.�.�...._._.Distance to nearest lot Irne__�..._____..._ V ❑ pits... ......Ii.----------Lining mater•ial__�_ ..f ..... Size: Diarneler _ 1- .--_--Depth......F_4 __-----------------• .r Cesspool: Distance from nearest well ___.__-.._-_--Distance from foundation................. . Lining material __.___-__..---------- --------------- ElSize. Diameter=-- -------------- --- ------------Depth----- ----------------------------- -----------Liquid Capacity- -------------------------gals. I Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--------------.-------.--_-_______-------. ❑ Distance to nearest lot line ------------ -------r----------- -----------------------------•------ ------- ----------------------------------------------- - --------- 1 Remodelingand/or repairing-(describe]----------------------- --------------------------------------------------------------------------------- -------------•-------------------------------- ---------------------------------------------------------- -----------------------------------------•------•-- •------ --------------------- ------------------------------------------------- -------------------------------- -------- ------------------------------ ---------------- -------------------------------------------------------------------------•------------------------------ -- --- . . '`----------------------------------- -•--•---------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws-anal rules and regulations of the San Joaquin Local Health District. I (Owner and/or Contractor) [Signe -- -�- - ---�:P� --- --- �..� �.�.- -� -- ------------------ --- - ------ -- - --- ------------- -- ip _ ..:� -- ---. _Title — ..... .. .By: ----- - — -------— T - { ) ---- -------- (Plot --.(Plot plan, showing size of lot,11ocation of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- -- -��`iC'rn'y 1 ------------- -- ------------------------- -------------- DATE-- /P'---- -~_ --------- --------------------- REVIEWEDBY-------------------------�--------- ----- --- ----------------------- - ------------- ---------------------- ----------------- DATE------ ------- --------------------------------------------- BUILDING PERMIT ISSUED_ A--- -- ---------- -- ---------- • DATE--------- -------------------------- - Alterationsand/or recommendations:----- --------- - - -------------- ------ ------------------------------------------------------- -------------'----- --------•---------•-•-------------------- �l - - - -------------- ------- ------ ----- ----- - ----------------- -------------------- '� ------- --- --------------. ------ ------------------------------- ------------------------------ = II . --- - -- ------------------------------ -------- - i FINAL INSPECTION BY:--- C ------------- ---------- -_ ---- - ------------ --------------- �I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. �N 300 West Oak Street 124 Sycamore Street 20.5 West 91h Street Stockton,California I� Lodi, California Manteca,California Tracy,California E.K.92M 1;67 Vanguard Press �� A°° r• II �I