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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT / --------------------------------------------------------- Permit No. ..Q�-� .�o.! --------------------_ - ------- -------------------- (Complete in Duplicate) .__________________ __ _ ___ ________________.___ This Permit Expires 1 Year From Date Issued 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 complianc with County Ordinance No. 549. lid .ham JOB ADDRESS ANPD,�LOCATION �21N ---------..----------------------------------------------------------------------------------------------- Owner's Name-�G- ------ ------------------------------------ Address------------- l '-�= ....--c---•---- ------------------------------------------------------•--------------------------- Contractor's Name_---- --- -- ---- --•---------••-- ----------- ------- ---------------------------------- Phone----------------------------------- Installation will-serve: Residence Apa tment House ❑ Commercial ❑ Trailer Court ElMotel F] Other ❑ Number of living units: Number of bedrooms 4-.- Number of-baths/'//__ Lot size ---17_451d5 ' "---------------------------------� Water Supply: Public system ❑ Community system ❑ Private �epth to Water Table -------- ft. \ . Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay Loam 171 Clay 'Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes [:] No E-] N FHA/VA: Yes ❑ o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic ank: Distance from nearest well—:�-E1_/..__Distance��from foundation-----A'._.-----Material---4O-- -------------------- No. of compartments--_____�--___-_-__.__Sizeb_/j'9�i1`Sl_Liquid depth_--�� --------- __ _. Dispos field: Distance from nearest well___.. �_l._Distance from foundation----- R f......Distance to nearest lot line✓t.1_.. ...... [/ �� -----------Width of trench----------------------------------- op f Number of lines____________ ________ Length of each line_______ .._ _._. . sr � Type of filter material-_---_S____ _______Depth of filter material--- length---��t f . __-__._--_--______- Seepa Pit: Distance to nearest well___AOO_ -_--__Distance froundation___1.D_.....__.Distance to nearestline S___ __-.____-_- __- _ ` �_ S-� Number of pits__ _--__-__._Lining material------ ro��______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------------------------ ----------- ------------------------------------------------------------------------- ----------- ---------------- Remodelingand/or repairing (describe):--------------------------------------------------------------------------•--------------------------------------------------------------•------------- ---------•---•-------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------- -------------------------- --------------------••-------------------------•------------------------------ ------------ --------------------------------•---•----------------------------------------------------•------------------------------ ----------------------------------- --- -------------------------------------------------•----------------------••-------------------------------- -•-------•----------------------------------------- ------------------ hereby certiLand ve prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, State lles and regulations of the San Joaquin Local Health District.(Signed)-------------- -- ----------- - nd/or Contractor) BY� l - ------- -----------------------------------------------(Title)------------------------------------- -------- -- (Plot plan, showing size of lot, location of sys em in rel ion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY . _.- ----- ---------------------- ---------------------------------------- DATE_.;_F_---4_-_4---_7----------------------------- REVIEWEDBY----- --------------------------------------- ......... DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------- ------------- DATE------------------------------------------------------------- Alterationsand/or recommendations----------------------------------------------- ._.--------------------------------- -------------------------------------.------------------- ---------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------•--- --------------------------------------- ---------------- ---------------------- ------------------------------------------------------------------------- ---------- ---•-•-----•------ ---------------------------------- - -------------------------------------------------•------ -•----------------------------------------------------------- ---------- ----------- --- ------------------------- FINAL INSPECTION BY:- l -------------------- Date---47V -�(' 7 - 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 F.P.CO.