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FOR OFFICE:USE: 4 -y/g fXS ------- ----- APPLICATION FOR SANITATION PERMIT Permit No. .__ .3- - - ------- (Complete in Duplicate) Date Issued __ - '�! ---- --- ------ This Permit Expires 1 Year From Date Issued -------------------- 1l. Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work hereiriidescribed. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION... - ----------------------------------------- ------------ ------------------------------- i ---------------- --- C "' �------------- Phone--- --------------------- •-------- Owner's Name____ �yy� D , Address_..---�-�•Y_-I+M----'--- r ------ Phone..--_--------------------------- Contractor's Name_ _ - r ��----------•-- -----•----•- ---- ------- --------------- ------------------------ --- - Installation will serve: Residence Apartment House [I Commercial ❑ Trailer Court E] Motel ❑ Other ❑ Number of living units: ___1_.. Number of bedrooms _._ Number of baths Z -- Lot size ___z ____----__�______..---M----------------------- -- Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table Jr ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0—Hardpan ❑ Previous Application Made: (If yes,date------------ --------I No � New Construction: Yes �No ❑ FHA/VA: Yes F�J -No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: [No septic tank or cesspool permitted if public sewer is available within 200 feet.) r^ Septic Tank: Distance from nearest welL___-------------Distance from foundation--44..........-_.Material__��zi� --- 5ize x X --------Liquid depth----4------------------ CapacitY �(y� �� No. of compartments___._------------------ .� �' s f Disposal Field: Distance from nearest well----- ----_____Distance from foundationU_1�-_ti___----Distance to nearest lot line_ � ` Number of lines--------6-------------------------Length of each line__' -..-:=Width ofrench. -A" - --- ------- --------- ------ mill ❑� , Type of filter material�tz G_A-------.-Depth ofi"filter materiah _-.-. Total length- __. d=--" Seepage Pit: Distance to nearest we1!_/ _ ______ ________Distance from foundation__-.____ _.__Distance to nearest lot line. ___.'. ______-. Number,.of pits.- -------/� -Lining material-----------------------Size:.Diameter_:_----- ----I-Depth------------- - --- - ---- ❑ - s # ?� Cesspool: Distance from nearest well-----------------Distanc,e from foundation.-.__.-------_____.Lining material_..-___-._.____-_____._;____-_...__.. ❑ Size: Diameter'------�.------------------- --------Depth_----------------------- -�.�----7------Lic(uid"Capacity Y ~'gals. ' r Priv Distance>from nearest well-------------------------.------------ - ---- - --Distance from,,nearest building- --------- __-_______________________ Y � i"y, ----- - ------ Distance-to nearest lot line----------------- --------- -------••------------------------- f r Remodeling and/or repairing (des --------------------------------- ------------------- } ' -. ?-, I r --------=----------•----------------- -- - __•_____________________________________________ f . . - _.__________.__.-_________ .� _________________________________________________________________________________ r 3 i 1 --------------------------------------------------------------------------------- -- --------------------------- ---------------------------------------------------- A I hereby certify that•I have prepred this application and that the work will be done in accordance with San Joaquin County ordinances, State laws,.and rules and regulations of the San Joaquin Local Health District. ` ` �` i -------- [Owner and/or Contractor) (Signed)------------------ '.._ r lk -- - -- ----------- ----- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). yz FOR DEPARTMENT USE ONLY _ n . " ' --------------- DATE-----2---� - --------------------------------- APPLICATION 5 ---------------------- APPLICATION ACCEPTED BY_ ,? r�------- •------- -- --- ---- ---------- i ------------------------- ----- -- DATE-------------------------------------- ------------------- REVIEWEDBY............................................. ------------ ------- ----,- -----------: - - - BUILDINGPERMIT ISSUED------------------------ -------------------------------------.._ DATE-----------------------------------------------_---------- 'k. r --------------- - ------ Alterations and/or recommendations:---------`--------------------------- ---- -------------------------------------------------------------- ------------------------------------------- ----------------------------------------------- k _ - ___________________ ___________________________ _____ k t —Date -- // FINAL INSPECTION `BY: --.-.-- 'L ----------- .. -- �� - CJ ----- - --�- - ------ } t SAN JOAQUIN LOCAL-HEALTH DISTRICT 6 1601 E.Hazelton Ave. 300 West Oak street 124 Sycamore Street 205 West 9th Street Stockton,California Lorli,California Manteca,California Tracy,California F.P.r;o.