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FOROFFICE USE: -- - -------- ------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. . --------=---------- ------ -------------------------- (Complete in Duplicate Date issued 6f____2.-K.7 _ . ---------I---------------------------------------.--_ This Permit Ex irks 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 AND LOCATION_____/!R_ _.--_�� `- Owner's Namef �—�� SW -------�-�------------ -- -------- - ------------------- Phone__-,'5" ' -3 -- Address....f�f - -------��/-- ----------------------------------------------------------------------------------------------- ----------- Contractor's Name------------ - A �/ '!l'c` ----------------- -------------------•------------------------- Phone_'��----------- •`3•!-------- � Installation will serve: Residence �partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size ------ - ----------------------- Water Supply: Public system ❑ Community system ❑ Private)g• Depth to Water Table aft. Character of soil to a depth of 3'feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam D Clay ❑ Adobe tR Hardpan ❑ Previous Application Made: (If yes,date.....---- ---------) No ❑ New Construction: Yes 21 Vo ❑ FHA/VA: Yes ❑ No ❑ lrt TYPE OF INSTALLATION AND SPECIFICATIONS: -� (No septic tank or cesspool permitted if public sewer is available within 208 feet.) L ,J �� i k: Distance from Septic Tannearest wel!_.• ��_f_Distance from foundation---.�Q-----.._.Material_. -f'`�� .___._.____ ET No. of compartments------>�-------------- Liquid depth__ _;�_.'._.____-___.-Capacity-ZX��-_--- Disposal Field: Distance from nearest well.-__._ ....Distance from foundation.- --Distance to nearest lot line___ __________ Number of lines------sz�-----------------------Length of each line_&O__ Width of trench-----.. ------ of filter material_ i_ 12{_ '...Depth of filter material___ -------.--.Total Iength____f6__ ------------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- El Number of pits----------------------Lining material------- -------------Size: Diameter----------.------------Depth_..------.----------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material.........___-------.--...._____--_.-_ ❑ Size: Diameter----- -------------- ----------------Depth---------------------------------- -------- --------Liquid Capacity-.--------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---._-_--_.---_-.--.----___----_-.-._. ❑ Distance to nearest lot line--- - --------------------- - -------- ------------------------------------------------------------------------------------------------- Remodeling and/or repairing jdescribe) - =------�_�- '------- - - -- '4,r"� ------------------------------------------------------------------------------------------------------------------------------------------------- --------------------- ---------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•----••---------------------------------- - --------------------------------------------------------------------------------------------------------------•------------------------------------------ ------------------------------------------------------------- -- - 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, and rules and regulations of the San Joaquin Local Health District. ` (Signed)---------- --------- ---------- ------------------------- ----------- -------- f] ----(Owner and/or Contractor) By: ------------ �C Title F"C„�-"_?.�'.�i' ------- -------- ----- Y �� (Plot plan, showing size of lot, location of system in relation 4o wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- -- -,--- ------------------------------------------------------------------ DATE- r f -- - - ------------------------------------- REVIEWEDBY----------------------------------------- ------------------------------------------------------------------------------- DATE----- -- ---------------------------------- BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------- ------------- DATE---------------------------------------------------------- -- Alterations and/or recommendations:--------------------------------- ---------------------------------------------------------------------------------------------- --------_-------------------- --------------------------------------------- ------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------ at - ,� -------------------------------------------------•---------- --- ------ ------- ---------------------------------------------------------------------------------------------------- ------------------------------------ ----------------- ------- --------I- ---- ------- ------------------------------------------------------------ ---------------------------- ------------------------ ------------------ -------------------------------- -------------------------------x--------------------- - -------------- --------- -------- - -------___----------------------------------------- _ n,0 FINAL INSPECTION BY:. .-.-__ _ ____. ----------- ------------ Date......... -� 0 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca, California Tracy,California