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FOR OFFICE USE: =fes ------------------ 16-p-3uI Grr�� APPLICATION FOR SANITATION PERMIT Permit No. . 1�.--,1 .7,� �� `r --k-j--------------- -� �'�--- (Complete in Duplicate) �� . 3--------------------_---__-_-------_--_-_....--. This Permit Expires 1 Year From Date IssuedDate 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 AN LOCATION_ ___..___:_ ._ l/ E' _ _ 1 I'� ------------- - ---------------------- Owner's Name-------------- ---Z-a---1�-�CA_ I-ti'S------------------------------ ----------------------------------- ------------------------- Phone------------------------------------ Address ... - v-------2&. .J)n� = - ---------- __tti�9_tt'15----------------------------------------------------------------------- Contractor's Name ` O ------------` ------------------------------------ Phone---•------------•------------------ ---------------- - ---------------------------------- Installation will serve: Residence [!I'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:f-.---- Number of bedrooms _z Number of baths 1_----- Lot size ------4,n-._�_--.-:�. _zj_________________ Water Supply: Public system 2--community system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[D,-Hardpan ❑ Previous Application Made: (If yes,date-----------------.--) No �ew Construction: Yes ❑ No §2'FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material----------------.----------------------._----_--. ir No. of compartments-------------------------Size-------------------------------Liquid depth--------------------------Capacity.-..-------••---------- Disposal Field: Distance from nearest well-----------------Distance from foundation...........---------Distance to nearest lot line................. ��si/.r,� Number of lines-----------------------------------Length of each line------------------------------Width of french------------------------------------ IType of filter material-------------------------Depth of filter material----------------------.Total length------------------------------------------ J Seepage it: Distance to nearest well_--- _- -----------Distance f� m foundation-_/_0........Distance to nearest lot lines__.-.___._ Vl Number of pits.___/_-_-._..----Lining mate ria l__Xc_�---_-_-Size: Diameter-3...'.........Depth-_e .�__n� _.. •� 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-------------------------------- ------------------------------------- --------------------------------------------------------------------- Remodeling and/or repairing (describe):---_----_---_--_-_______f-tom __ _________________: ______ 6 --------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------- --------------------- A ----------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ =t' ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat ws, and rules andregulationsof the San Joaquin Local Health District. _j; ocation _-.-_--_-__Owner and/or Contractor (Signed)------ ------ - ( / ) B �' --- - ---- ------ ------------ ---- rile-. y• ( ) e--- -------------- -- - ---- --------- (Plot plan, showing size of I of system in relaon to wells, buildings,-etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.--------- _____. DATE----------------- __ 'f`------__�-_--___--_-_-__ - -------------------------------- -- -- -- - - - REVIEWEDBY------- ----------------- ---------------_-- -------------------------------------------------------------------------------- DATE------------------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------ --------------- ------------------------------- DATE------------------------------------------------------------- Altera+ions and/or recommendations:--- --- ------------------ - - - - - - - - - --------------------------------------------------- ---------- -------------------- ---- /-FSS' x�'n,�.�,, - ---------------- ---------- -------------------------------- ---------- - --------------------- -------------------- --------------------------------- ------------------•------------------ ----------------------- ,,�01",e -1 -� S FINAL INSPECTION BY:--------L '-------------------- - ----------------- Date------ ----------- -------------- ------------------------ 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