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FOR OFFICE USE: - ------------------- ----------------------------- - - APPLICATION SANITATION PERMIT Permit No. ZZ? - (Complete in Duplicate) -A 1 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 he ork herein described. This application is ma a in com lienee with County Ordinance No. 549. V "'- 1��I� 'j" JOB A RESS ANDDLOCCATIO E------ -1--W-_--------/2a_-•----a0F�. ��' i _ __. Owner's Name-------- __ _F: F-�-----------------<ibM_e ' �n - Phone_.. Address------------�--------- ------.--- —-------_37-h-,-----------/ �" C} -----------------------------------------------------------------------•---= Contractor's Name-----Q-------- 1 ------------------------------------------- ------------------ ----------- ---------------- Phone.------ -------------------•------- Installation will serve: Residence, Apartment House ❑ Commercial E] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _h__ Number of bedrooms i___-_ Number of baths _.J.__ Lot size -__..__________- Water Supply: Public system ❑ Community system Private ❑ Depth to Water Table -V ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------).No New Construction: Yeso FHA/VA: Yes ❑ No]/ TYPE OF INSTALLATION AND SPECIFICATIONS:- _ � E] (No septic tarik or cesspool permitted if public sewer is available within 200 feet.} ... Septic Tank: Distance from nearest well_________________Distance from foundation_.______-.-----Material_____..._.-_----__.___..-___._______._._______-- a��j-//il'C�r- No. of compartments--------------------------Size------------------ -- - - - -- Liquid depth-------------------------Capacity `- Disposal Field: Distance from nearest well.._...�O----_Distance from foundat ion__.o. __.--Distance to nearest lot line.IV __ r_._1•�Qk Number of lines------------- � ' Width of trench------_— -_-.-----_;i F �------- -----------Length of each line---:� ---•-------- -�;---- � 1' Type of filter material___._-C ..._Depth of filter material4_-__ _ __ Total length----------- -_______--------_ 1{! �._ - Seepage Pit: Distance to nearest well_____________ _____Distance from foundation__-----------.----- Distance to nearest lot � line__.________._. ❑ Number of pits -----------Lining material--------------- ----- -Size: Diameter---------------------- De th_------------------------------ Cesspool: --------------------------`:Cess ool: +y Distance from nearest well_______..__.___Distance from foundation_-_________________Lining material__._...________________..______� ❑ Size: Diameter Depth -------------------- q id Capacity-. gals 4 Privy: Distance from nearest well------------------------------------------- -- --Distance'frorr nearest'building------------------------- ❑ Distance to nearest lot line.-.._____.____________________-----------------------` ----------------------------------- --------------------------------- -----j Remodeling and/or repairing (describe):-------------------------------------- • - - ---------------------- -- ---------------------------------------------------------- -----------•--------- ------------------------------------ --- ----------------------------------------- - � ------------------- --------------- 4 , 4 ______________________._______.___.__-__-_--__..__..__________-_-______.____________-________________________--_________--------___________-___..________---______.._.._______________.__________...---------_--..___.-___._.___- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I s, and rules an egulations of the San Joaquin Local Health District. (Signed} t L --------------------------------------------------------------- ------------(Owner and/or Contractor} By:--- ------------- =------=----------------------- ------------------------------------ ------------------------(Title)---------:------------ ------ .---- -- ---_--- --- - - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__777- � ---------------------------------- DATE -�� - _�?---------------------- REVIEWEDBY----------------------------------------------------------------•--------- --------------- ------------------------_ DATE_--- --------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------- -------- DATE ----------------------------- = Alterationsand/or recommendations-------------------- ----------------------------------------------------------- ---------------------------------------------- ------------------------------ --------- --------•-------------------------------------------------- ----------- ----------- ------------------ ------------- _ we' ------------------------------- ------------------•--•---------------- - -------------- ---- ------------------------------------- . --•---------- -- --- ---------------------------- ------------------ --------------- --------------- ----- - -------------- ------- FINAL INSPECTION ---- -- -- --- - ---- ---. ..- Date----------- - ------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Harelion Ave. 300 West Oak Street 124 Sycamore Street 245 West 9Th Street Stockton,California Lodi,California Manteca,California Tracy,California r•.P.co.