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FOR USE: APPLICATION FOR SANITATION PERMIT Permit No. ........- -,• --- ------ ------- -------- ------------------------ Complete in Duplicate) �_ .. �. Date Issued -______- This Permit Expires 1 Year From Date Issued Application 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 AN ..LOC TION-----. 0__ - ---------A,0------ - ---------------------------------------------------- ` Phone .Owner's Name----_�I-1C4106-1� ------------------------------------------------ Address . •--------------------•------- ------------------------ Contractor's Name--------------- ------•-- -------------- ---- --- ------•-----------"- ------ Phone---------------------------------- Installation will serve: Residencenor" partment House ❑ Comme tial E] Trailer Court ❑ Motel ElOther ❑ g baths :_ Lot size _ ! X-��----------------------- Number of liven units: __.�._ Number of bedrooms -- Number of Nater Supply. Public system F!9� ommunity system •❑ Private 0 Depth to Water Table ft, Character of soil to a depth of 3 feet: Sand ❑f' Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay-El Adobe ardpan ❑ ; Previous Application Made: {1f RS6,11te--------------- No [jo-'14ew Consfruction•: Yes 6;�_.Wo ❑ -FHA/VA: Yes ❑ No [jg� TYPE OF INSTALLATION Af1D SPECIFICATIONS: i (No septic tank or cesspool permitted if public sewer is available.within 204 feet.) `' � ; B Septic Ta f Distance from nearest well_._.�'_-`___Distance from foundation___,/_.-_-------- ial._. - -_- "-=-- ------- l t No. ofwco artments.._.R__._-�-�-� - ��--` �---- p�--"__-Des a�t�e to nearest lot li�.>S_------ ` Size___ Liquid de th___� _ _ Ca acit �"i`�-j Disposal Field: Distance fr m nearest well-.-•,� -Distance from foundation-_ =----- Number of lines______ I 'Len th of each line. >� rWidth of trench_-- ,_ _.._,"_"_._____ off.,. j------------ . g ,��r t, �Type'of fel r material___,1_�rdl__ -Uepfho fifer material--_�_�k--:.__----- length_.;$ ?!_______________ .. ` Seepage Distance tw nearest well------.._--fn-----_Distance�f om�fJoundation_.l_4._____._.Distance to nearest lot lire- �____._ Number of pits---t��-------Lining material-fes _.3lrt Size: Diameter_ .-:.----Deptha� _ ------ ---- Cesspool: Distance fi`om nearest well-----------------Distance from foundation..._...............Lining material----------------------__-.----,----_ ' ❑ Size: Diam ter-------------------------- --------Depth------------------------------ - --- ---------------Liquid Capacity--------------------------_gals . � Privy: Distance- r m nM ear welti�'~ "" ..- :_.--"--__-.::-------i`s'a cnef om nearest building ----------------------------- t ❑ Distance to nearest lot lire--------------------"------------------------ ----------------------- ----------------------------------- `------------------------------- Remodeling and/or re airing (describe):---------- �1 i ------------- ---- ------------------- ------------------------ "--------------------------- - --------------------------------- I hereb certify t'at I have re ared this application and thf ------------------- -------------------------------------- - --` ------ -- - ----- ------------- 'hereby -------=----------------------- ---------------------------------------- -- y y prepared� at.the work will be one in accordance with San Joaquin County ordinances, State la d rules an ulations of the San Joaquin Local Hem alt�h strict. (Signed)_ ��. .�-- .-,a-- -- - (Owner an or Contractor) � �J ------------- - 6 . (Title).... ------------------ • r 4I (Plot plan, showing size of o , location of system in relation tow s, buildings, etc., can be plac4d on reverse side). i FOR DEPARTMENT USE ONL APPLICATION ACCEPTED BY--------------- ------ ------------ ---------------- l C/DATE_1------- =� - ---- ---- ---------------------- REVIEWED BY---------- -- ----- --------------- ------------- --- ----------------- -------------------- DATE--I'----------------------•---- ---------------- BUILDING PERMIT ISSUED---------------------------------------------------------------------------------------- DATE.__ . �= Alterations and/or recommendations:_-_-__..__._ _. `-�----------- ---------------- Sr. » �� - ------------ -------- -- --- - Y' - -------- ---------- F�NALyINSPECTION BY:- -- - -- ------ ---- -------------- - e t: Date� SAN JOAQUIN•LOCAL HEALTH DISTRICT: 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California i rt