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FOR OFFICE USE: ------------------------------- ----------- APPLICATION FOR SANITATION PERMIT Permit No. . ....... -------------- ----------- (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 compliance with County Or - ante No. 549. JOB ADDRESS AND CATION � � •� ----------- - t Owner's Name------------ r ------------- Phone- 2_+___: - --------•--------------------- . _Q. 4 -- ---------- Address Contractor's Name-, --------- ----------- ------- : - ----t -- f�2r=t�R..__ Phone i� = ��_-• Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court_ ❑ Motel ❑ Other ❑ Number of living units: 1_____ ber of bedrooms .7��Iumber of baths _/.__ Lot size; _cO---_'` r_______________ Water Supply: Public system 2 Community system ❑ Private ❑ Depth to Water Table:.6_,0'ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan 0 Previous Application Made: (If yes,date....................) No ❑ New Construction: Yes ❑ r No FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 7/ (No septic tank or cesspool permitted if yyp��ublic sewer is available within 200 fe/e�t.) ; Septic Tank: Distance from nearest well_J` „1Qistanc� from f u ion- -L�-f--------.Material j7 --------------- ---- No. of compartments.. ________ Size Jam__ JLiquid depth__. �..`�____.-Capacity__ _ _ , ®f - r Dis o al Field: Distance from near sf well��---Distance from foundation_- _____------Distance to nearest lot lme---____�_ Number of lines_________ ___________ .__ Length of each line____.eP._�--_--___Width of trench.-- ��_-__---------- Type of filter materi Depth of filter material------1_9!"_.-Total length-----.-_ Q Seep ge Pit: Distance to nearest well . 0 ----_Distance from foundation___ ___.Distance to nearest lot line___.5--.-- Number of its..ff _.Linin material--Ria-I _.Size: Diameter--_ ----_----Deptn_____ - ...-�_ Cesspool: Distance from nearest weld----_____-__..__Distance fromndation------------------- Lining material_-..----------------.____.._.______.._. J ❑ Size: Diameter------ ---------- --- -------- ------Depth---------------------------------------------------Liquid Capacity-------------f--------------gals. Privy: Distance from nearest well......._---------------------------------.-___.-.-_Distance from nearest building-------.---____---_______-.----.--.-. ❑ rDisf5nce to nearest lot line-- ---------•----------------------------------------------------------------------:------------------------- -------- 9 tt - g (describe): -------- Remodeling and/or re a�r�n estribe):___-'__....��t- ------------------- �_ - -------- ------------ - --- -- ---- --- -- --- --------- --- - ----- - -------- I hereby, certify t I have prepared this application an t at the work will be done in actor nce with San Joaquin Count ordinances, State laws, anA rules and regulations of the San Joaquin Local Health District. l a (Signed)---------------- t (QwaeF-a�rder�Contractar) SrR_rlc TAfVK S ------------------------------- Y* --- B _�9T5_E:MinerE31ILc' (Tt �e} (Plot plan, showing size 8Yf6*,'l 1i46W3$f system in relation t wells, buildings, tc:, can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ....... ------ DATE.------ - .—tea ��' ------------- - REVIEWEDBY------------------------- --- ------- -.- ----• DATE----- ----------------------- ------------------------ BUILDING PERMIT ISSUED-------- --------------------------------------------------------------------------------------------- DATE------------------------------ ------------------------------ Alterations and/or recommendations:------- -- ------- --------------------------- ------------------------------ ---------------------------------------------------------------------------------- --------------------------------------- ----------=°------ ---------- ----- ------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------------- -------------------------------------------- --------------------------------------------- --------- -- --------------------------•----•--------•----- -----•------- ------------ -------------------------------------- F€NAL INSPECTION BY:-..... ---� --`--Com--------------------- ---------- Date. �----�� - - - -- ------------- SAN ---- - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.ka:elton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California r•.P.c o. I. _