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FOR OFFICE USE: ---------------------------------------------------- Pi .. APPLICATION FOR SANITATION PERMIT Permit No. ------------------------------------------- - ----r (Complete in Duplicate) Date issued -�X02 - -------------------------------------------------------- This Permit Expires I Year From Date Issued fAWr 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. t JOB ADDRESS AND LOCATION.. ' -------- ------ Owner's Name--y-----Ard �'-uz----•----- r� Phone Address r _�,....... = � � ... ------------- Contractor's Name_- .fid! ------------e__�v --------------------------------------- Phone-----------_------------- ---•---- Installation will serve: Residence M Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I---- Number of bedrooms Number of baths _1--- Lot size ------------------- Water Supply: Public system ❑ Community 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.T 4_ Previous Application Made: (if yes,date-----_-------------) .No ❑ New Construction: Yes ❑ No ❑ PHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 70 tv Septic Tank: Distance from nearest'well__4141--- -Distance from f777 oundation---- .----- Material ----- --------------- - f No. of compartments----------------------- 4"---- ----------Liquid depth------�.----.------. Capacity- -- 7i ---Size-��-�--- � ------ I Disposal Field: Distance from nearest well--S-0-r.--.._Distance from foundation.- P�---------Distance to nearest lot ine-�~----------- Number of lines--------------------------------Length of each line---- --------------.Width of trench----y'�---------------------- �' Type of filter materia--R-----:---___Depth of filter material------/?__-------Total length-a--------------------- ------- If Seepage Pit: Distance to near f well--- ---__,--:Distance from foundation--_-- ---...-- #�n ce ,nearest lot line--S----------- Number of pits- --__._ -----Lining material- '...---__.Sizebiometer-- _- � Depth..-�'7------------------- Cesspool: Distance fromnearest 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--------------------------------------------------------------------------------------•----------------------------r----------------- 4 iRemodeling 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, and ules and re ulat' ns of the San Joaquin Local Health District. . ` (Signed) _ --- _--------_----(Owne-rand'/or Contractor)- - ------- ------ - ---------- --------------- ------- - --------------- By:---- ------------------•---------------------------I---------- ------------------------------------------------------------------(Title)--------------- _ --Y._------- ---- -- --------- -- r (Plot Ian owing size of lot, locat'�ta—n ark system m relation to wells, buildings, etc., sari be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- ---- ----------- -- ------------------------------------- DATE--- ----------------------------- REVIEWEDBY-------------------------------- ----------- ------------ --------------------------------------------------------- --------- DATE---------------------------------------------------- ------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------- ---------- DATE------------------------------------------------------------- Alterationsand/or recommendations:--------------------------------------- ---- ------------------ -------------------------•------------•-----....-------------------------------------------- ---------•------------------------------------------------------------------------------------- ----------L------------------------ ----------- ------- -- - ------------------- -=------ ---------- --------- ------------------------- - ------------------------------------------------------------------------------------ - - kk ----- -------•----------------------••--------•-•----------------------- ------------------------------------------------ FINAL INSPECTION BY: - --- -- -- --- - ------------ Date---J---.3 O ' „ a . SAN JOAQUIN LOCAL HEALTH-DISTRICT -' 1601 E.Ifaxelton Ave. 300 West Oak Street a 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California c.