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FOR 0,-4;k' USE: _ ------------------- ------------------------ APPLICATION FOR SANITATION PERMIT Permit No. ---------------------------------- -------- A,.. (Complete in Duplicate) Date Issued _��Y,lln _._._---_--_-__-__--____-_-_-_-_--__----------------- This Permit Expires 1 Year From 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. M7" 51 VE—Z JOB ADDRES AND`L CATION At RT /��ta ----------------------------------- -Z—. O� ----� -- ------- -- -j ---- ------------ � ------------ Owner's Name------ -- _� j �lr------- �6 -- -- - Address7V - '-...................................................................................... sip / me Contractor's Name---------- _--------------------------------------------- -- -- Phone................................... Installation will serve: Residence e Apartment louse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: 1------ Number of bedrooms Number o baths ---/-- Lot size _ J�' �,}: -------------------------------------- Water Supply: Public system ❑ Community system ❑ Private Number to Water Table __fes__ 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 �ew Construction: Yes ga- �o ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) CFIu`,riNfr, Septic Wank: Distance from nearest well---- ©. _Distance, from�fQ. tion_ .__�l__ -Materipl__�_YS_i9WO'�"� ° . C] Cxl51'l/� o. of._com artments____..2-_ __Size___. _ �,1_i uid de th Capacity oQ _-_ P_ F q P. -I --- P Y••• Disposal Field: Distance from nearest well-_5_0 -.-Distance from ound ion.....tQ______- nce to nearest lot line................. 0" Number of lines------------�----_----------Length of ediAll.ine-,--0_-----`?0--------Width of trench-------- ___.._- �tlSfl�� Type of filter material-__ &C-A--_Depth of filter moterial_-.-�- __ a Total length_____________-_-__ze--_._--_.__-_ JITSeepage Pit: Distance to nearest well-------------_--------Distance from foundation____-__..-_-_-___--.Distance to nearest lot line----------------- to ❑ Number of pits--------------.-------Lining material----------------------- Diameter.................-------Depth-.---------------_---------...... Cesspool: Distance from nearest well----------------- from foundation_.------------------Lining material--------------------------------- -T I --- 0 Size: Diameter------------------------------------.Depth-.--------------- ---------------------•------------Liquid Capacity---------------------------- Privy: Distance from nearest well---------------------------------- --------------Distance from nearest building-----------------------------------------M ❑ Distance to nearest lot line------------------------------------ -----------------------------------------•---------------------------- -------------------------- 0 Remodeling and/or repairing (describe):-------15FRTKt ----T-/_`XK------PUM_pa-D_t----Re -_- ----___------- -------------------------II—V5'r ---- ----r_7jA-tom--A------------------------------------------------------ -------------------- ----- ---------------- ------------ -- ---------- -------- ----- ------------------------------- = -------------------------------------------------- ----------------- --------------------- --------------------------- - ---------- ------------------------------ - ---- ._ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, an, rules and regulations of the San Joaq in Local Health District. � f (Signed)--------- ------;� - ----- - ---- - - -----------------------------------------------(Owner and/or Contractor) BY: --------------------------------- ----------------- u. ---------------(Title) --------------------------- - (Plo+ plan, showing size of lot, location of syste in relation to well , buil s, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY q APPLICATION ACCEPTED BY--------�-r,,--47-�---------------------------------------------------------------- DATE--------�� / � '------------ REVIEWEDBY----- -------------------------------------------- -------------------------------------------- ---------------------------- DATE------ --------------------------------------------------- BUILDINGPERMIT ISSUED................------------------------------------------------------- ------ DATE--------------------------------------- ------------------ Alterations and/or recommendations------------------------------------------------------------------------------------ -------------•--- ------ ---•-----------•-•-------------•------- ---------•--•--•- ----------- ------------------------------------------------*IN----------------------------------------- ••----------•------•---•---•--•-------------------•---•-- ---------- •-- -------------- --------•----------------•- ----------------...... ------------••-----• -•------------- ---------------•-------- •---••------------------- -•--- ----•---------- -- ---------- - - - ----------- -- ------- ----- --•----------------------------------•-•----------- ------------------------------------------------------------ FINAL INSPECTI BY:.. 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 F.P.CC. ►