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F R OFFICE USE: 1/ jo -- ------------------- APPLICATION FOR SANITATION PERMIT Permit No. _ s --------------------------------------------------------- (Complete in Duplicate) /�y This Permit Expires f 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 compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION-. � a q�clv_-2 va 01 Owner's Name---- _ 1 - ._- Phone_____________________ Address-------4- INal_---•----- - ----- -- - - --------------- ---------------------- - -------------------------------- -p-- -- �-- - -- Contractor's Name---------- �f - v----•------------------------------------------------•--•----------•------.------------•- Phone Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _�"__ Number of bedrooms __--. Number of bafKi __04__ Lot-size_ .�Xa/ .................,...__.____.._____ Wafer Supply: Public system [Community system ❑ Private ❑ Depth to Water Table $eft. Character of sail +o'A depth of 3-feet: . Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0--F ardpan ❑ a - Previous Application Madel (If yes,date____________________) No g]-- New Construction. Yes ❑ No 2'FHA/VA: Yes ❑ No p_ TYPE OF INSTAL_LAT10N AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) t Septic Tank: -Distance from nearest well-----".."'------Distance/from foundation__- ----- ---Material__- __.�_.� ; [l}�- No. of compartments____-,- -----------------Size_ _ depth-----�V ----------Capacity._. P______ Disposal Field: Distance �rom•nearest well.__.' ____ Distance from foundation.....1j!"�?_"...Distance to nearest lot _ __.. i [( �' Number of line's---------- Leng'tfi of each 'line____'yj_______-__: -------Width.of trench.___.2-_�- Type of filter material_, /� i.Depth of filter material_---./Ir-i-----_-Total I"engtli-------9_,!!�-__ _____________________ Seepage Pit: Distance to nearest well ____—-----------Distance from foundation-...vr_;..P.'__.Distance`f6,hearest lot line__4S_~__-- .j} Number of pits-------/-------------Lining material.___ __.Size: Diameter----"_ _"i Depth___-Z�1-------------------- .J% Cesspool: Distance from nearest well_________________Distance from foundation--------------.----.Lining material---------------------.--------------- ❑ Sae: Diameter.-.---- `------------------- ----------Depth-------------- -------------------------------------Liquid Capacity_:----=-------------_-....gals. i Privy: Distance from nearest well _____.________`.-------.----------------------Distance from nearest building----------_-------------.----------------- Q-1 ❑ Distance tonearest`lot`line- ----------•----------------------------------------------•-•---------•------------------------------ --- --------------------- - Remodeling and/or repairing ldescribe).:-: ------- ------ ---- --------------••-------- --•--•-----------••------------•---------•--------------------•------------.-_.---------------------------------------------------------------------------------------------•--------------------------------------- - ------- --------------------------------•-------------------• -------------•---•-----•-----------••-------•----------------------------------------------•------•---•----•--------..-----•--- --------------•-----------------------------------------------=--------•------------------ ---------------------------------------------------------------••-----•------------------------------------ ------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin.County J ordinances, State laws./pd rules and regulations of +he San Joaquin Local Health District. (Signed) -------J------------------------------------------------------------ --------------------------------- -Contractor) By:.......-----------_.......-----------------_------------ ------ -------------------- ----------ITi+le) /��y--------------- ............. (Plot plan, showing size of lot, location of s m in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY -, I APPLICATION ACCEPTED BY----------------------------------- --- ` DATE------- ---- _ (fl REVIEWED BY. DATE ". BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-----------------------------`'------------------- .......... Alterations and/or recommendations--------- -----------------------------------------------------------•------------------...........•-_-.-------------------------------------------------------- ---------------------------------------- -------••------- a -------------- - -•-------• -----------------•--------------------- ----------------------------------------------------------------------------------------------------------------------------- ---- -• ------------- ......................................... --------------------= -- ----------- ---- ---------------•-----------------------------------------------------------------------------------•-------------------- F FINAL INSPECTION BY:----.'e,`- (\1---- Date r � -- ----- -- - SAN (Q JOAQUIN LOCAL EALTH DISTRICT 130 South American Street 300 West Oak Street 24 Sycamore Streets 205 West 9th Street i Stockton,California Lodi,California Manteca,California; Tracy,California E6.9 REY18E0 B-68 F.P.00.SM 6-60