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FOR OFFICE USE: ' rs- ------..-.�. __--. APPLICATION FOR SANITATION PERMIT Permit No. ._2jI_yI/ .. ------------------- ------------ --- --- ----------------- (Complete in Duplicate) ........ This Permit Expires 1 Year From Date Issued Date Issued 7 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- 5 JOB ADDRESS AND L TION- ®� -----� Gam-}----- -, --- p a Owner's Name ------ ---- ---•-----•------------------ ------------------ -------- --------I------- Phone--------------------------------•--- Address-------------------•--- ------------ -- ------------ ------ ------ --- --- ---- y- , Contractor's Name- ------ ---- --- Irk---- ------- Phone--- g Installation will serve: Residence partment House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: /_____ Number of bedrooms 1—Number of baths _r__ Lot size J"73711 X-0 4.0111�a ------------------ Water Supply: Public systemImmunity system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: [If yes,date------------_______ I No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: g o septic tank or cesspool permitted if public sewer is available within 200 feet.) Se is Ta , Distance.from nearest well_________________Distance from foundation-------------------Material----------------__.-------_______---_-----__-__-. No. of compartments------------- Size--------------------------------Liquid depth.-------------- - - - ----Capacity-----------•----- ----- sal f d f Distance from nearet well- INA __ istance from foundatio ,l(-_-f_-Distance to nearest lot line_-,cam --I 517( DI umber } of lines----__- -_-,--Length of each line_--, _Q!----------Width of french--.P- .�.I --------- _ i Type of filter materia p �f epth of filter material------ ____---Total length------------------------ ---Q------ I Seepage Pit: Distance to nearest well----------------------Distance from foundation__________-_..__--- Distance to nearest lot line---------- ------ ,__.S ❑ Number of pits--------------------Lining material-------------_ -_-----Size: Diameter-----------------_-.--.Dept h-------------------------........ Z' P Cesspool: Distance from nearest well-_____-----------Distance from foundation--------------------Lining material----------------- _------------:---- It ❑ Size:.Diameter----- -------------------------------Depth----- ---------------------------- -----------------Liquid Capacity- --------------------------gals. (T+1 Privy: Distance from nearest well ______--------------------------_-----------------Distance from nearest building--.-_.--_____---------__-______------._. ❑ Distance to nearest lot line----- --------------------------- -----------------------------•-------------- -------------------------------------------------------------- d Remodeling and/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, an4frules and regulations of the San Joaquin Local Health District. ✓✓ (Signed)----------------�a �` a��i -------------------------------------------------- ----- ------ -----------------------------------(Owner and/or Contractor) , 1 SEP-171C TANK SERVICEBY� -291-5-E-Mintsr-of V---:--HD P:384 ------------- e------------------------ --------(Title)----- --------------------- } - - ------------ (Plot plan, showing size 11 location oLi ystem n relation to , buildings, c., can be laced on reverse side. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------- %-1-------4�2_ -------------=-------------- DATE------ �G.-�-------------------- REVIEWEDBY-------------------------------- - ---------- --------------------- --------------------------------------- DATE BUILDING PERMIT ISSUED--------- -------------------------------------------------------------------------- - DATE Alterations and/or recommendations:------- -------------- -------------- - - - ----------------------•------------------------•--= ---------------------------------------------------- --------------------- ----------------- ----r------------------------------------------------------------------------------ --------------------- ------ ----------------------------------- -------- -------------------------------------------------------- ---------------= -------------------------- ------ •------------------ FINAL INSPECTION BY:. - ----- --- --- ---- 1� ` ------------------- SAN- ---- -�- --�------- Date- �- - ---�--------- -�--�-- - , ---- ------- - ------ -- �------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1801 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 O.