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FOR OFFICE USE: I� ---------- ---- ------------------------- -------- APPLICATION AOR SANITATION PERMIT Permit No. a2.�_�Q- -------------- -------------------------- --- -------- Complete K Duplicate) o�Z67 1 __. _._ This Permit Ex ires 1 Year From Date Issued Date Issued ___________________-__ ------------------------------------------- --- -- ) 2Application 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_ ;L_ - ---, ll----- -----:----- - 1---- - -- � �� Owner's Name----x*-`--_XA- - -1 -------------------- --------------------=--------------- -------------------- ----------------- Phone-----------------------------••---- a Address-----/_.y_4----0-4 ..�'� �— 1 _ / /!-------------------------------------------------------------------------•-------------- ------------------------•- � ' Contractor's Name _ ----------,--------------------------------- ------------ Phone Installation will serve: Residence @ErApartment House ❑ Commercial ❑ Trailer Court E] Motel 0 Other ❑ Number of living units: _ __ Number of bedrooms____ Number of baths ,r9__ Lot size - - •------------ -- �l i Water Supply: Public.system ❑ Community system El: Private ��epth to Water Table,-e_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--------- ----------) No ET'� New Construct-ion: Yes ❑ No FHA/VA: Yes ❑ No TYPE OF OE INSTALLATION AND SPECIFICATIONS: F I (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tan Distance from nearest well------.----------D.istance from foundation___________________.Material_-______-______-________-_________---___------! l� No. of compartments------------------------ Size-------------------- -----------Liquid depth-------------------- Capacity--------------------= p �� , • _ _ Distance from foundation__`.__-.___.-Distance to nearest lot ____ _ . Disposal Fief' Distance from nearest well.-� �ength of each line___ __ '� r _ Number of lines`----- LF d4-a---------------Width of trench-t-- } ` Type of filter rrateria/ epth of filter mate ria l__AX7_ --------Total length___- --------------- Seepage Pits-. Distance to nearest well._.�r�__eY7---------Distance from fo ndation___._�Z-0___--xDDistan e to nearest lot line__-�c---- Number ofd`pits-_ -_ _ Xe rLing, mai erial__ fl ---Size: Diameter-_cJ_.- Depth_ �-- Cessol: Distance from nearest well_______ '_._-Distance from.„foundation- `_'"'y____ Lining material_.___-------------___________-------- ❑ Size: Diameter---------- ------- ---- _.- �y ------------Li'g6id Capacify__ gals. - ---- epth.., ----�-~------�------ - ---- 9 p Y-------------- ------------ Privy: Distance from nearest well------------------ ------------ -y _.-------------Distance from nearest building------------------------------------ - ❑ Distance to nearest lot line - f ' Remodeling and/or repairing (describe)---------- !//7 .f ��'� �- -- ---------- ------- --------------------------- ----------•-- ii t-----------------------------------------------------------r ,. 4 --------------------------- -- _..-_. ----------------------------------------------------------R r I herebycertify that I havere prepared this a lication and that the work will be done ini t y p p PP accordance with San Joaquin County k ordinances, State laws, and rules anal regulations of,the San Joaquin Local Health District; k (Signed)------------------- -_ ( ----- ---- 3 ------------------------------------------------ ontractor) , BY= ------------ -' ------ -------------------------- --------------------------(Title} i 2 A ",(Plot plan, showing size of list, location of system relation to wells, buildings, etc., can be placed on reverse side). � ; l ' FOR DEPARTMENT USE ONLY ' V l 1 APPLICATION ACCEPTED BY------- --- (_� DATE ` ` h ------------------------------- REVIEWED BY----------------- --------------------------- - -- ------- ------`----------- ---------------------------------------- DATE------------------------------------------------------- - `:-= BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE----- ------------------------ ------------------------------ Alterationsand/or recommendations:--------------- - - -- - ---------}---:---------------------------------------------------------------------••--------- -----•------------------------------ --- I --------------- -------------------------------------------------------- ---------- -------------------------------------- -------------------------------------------------------------------------------- ....... .________ -___-__-_- _.____._-_-_____.____-__________-_______-..-.._______-_-_____-___-___-_-_-_.-----__-_-__-_----_--_--_-----_--_ ________________________________________ ......_._.______.__.__- _- _--_-_____ FINAL INSPECTION BY:......G.:-............ -----Eh--------- ----------- s -.- Date-- ----------- --- ------------ -- ---------------------- ----- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street:: +� 124 ycamore Street 205 West 9th Street k l-i Stockton,California Lodi,California `' Manteca,California Tracy, California F,RCO, - I