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FOR OFFICE USE: -------------------------------------------- _________.__.._._______________________ ____.___. . APPLICATION FOR SANITATION PERMIT Permit No. ...... d. .... _..------ ------------------------------------------------ - ------- (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 Ordinance No. 549. JOB ADDRESS AND LOC`A`TI�ON,r- ! 2_3,__,_5 -1 Ay MTC -------- '. / - Owner's Name---------- ................... --- ----- Phone.................................... Address....................../.�i1-.r�-3_._5 A-1 aeo a7 = Contractor's Name Q _' ... ---- .................... Phone---------------_- ................ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ : __ Number of bedrooms -2— Number of baths---/-- Lot size ___. ►+CRE AG "-_______________________ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table 1� ft Character of soil to a depth of 3 feet- Sand gi--travel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date------------------- No New Consf�uction: Yes ❑ No 59--'IfHA/VA: Yes ❑ No J' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pu,4lic sewer is available within 200 feet.) Septic Tank: Distance from nearest well------- 0_Distance from foundation---------A)__..MaterialCQn�eR_ 7"-�---------- No. of compartments_-_ .�--__ --Size___._�4 X�/Q--- quid depth _ Capacity... +DisposalField:Field: Distance from nearest well .5_0-_Dist ance from foundation ` Distance to nearest lot line_--45— Number of lines__- __ r ---__-Length of each Width of trench _ line__ __. ` ..,.�-- -- ----- � S'4� 5� trench---- --------------- Type of filter material----IQ__ i__Depth of filter material----I� "......Total length---._f ------------------------------ Seepage Pit: Distance to nearest well-..--- ---------------Distance from foundation____:___-_..-.._•_-.Distance to nearest lot line----------------- F-1 Number of pits--- --..----------_Lining material-------------------- Size: Diameter-----------------------Depth------.-_.-------•--------------- Cesspool: Distance from nearest well .-_ . ._ -_Distance from foundation---------- Lining material. _ -------------- Q ❑ Size: Diameter- -- --------- - 1' -- -------- .Depth----- -- ---- - -------- - --- - ---- Liquid Capacity ---- ------..gals. Privy: Distance from nearest well-----__.---------_------------------------------Distance from nearest building--------------------------___.._.---------- lJ" ❑ Distance to nearest lot line------aa----------- - = Remodeling and/or repairing (describe):____-. . -_ � -.:I7_ P/41R-_-_�}•_-f?EPtA XI,5T"/ n/Er- 57`1= ��,-- �------ \!' -----•---------------------------------------------•-------- ------- ------ ----•---,-.----------------------• ----------------------------------------------------- --------------------•------------------------ ----------------------------------------------------------------•-------•------------ ----------------------------------------------------------------------------------------------------------------------------------- --------- ------ - --- --------- -- ---- ----- ------ ---------------------- --------- --------- ----- --- --------- ------- -- --- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State s, and r es and r, gulationg the San,Joaquin Local Health District. (Signed) --- ---- -- ----- -------- - --------(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 J APPLICATION ACCEPTED BY------- !_ __ ._4 =----------------------- -----. DATE------------ REVIEWEDBY-- ------------------------------------------------------------------ DATE- BUILDINGPERMIT ISSUED------------------------------ --------- ----------------------------------------------------------- DATE------------------------- ----- Alterations and/or recommendations--------------- -• ------ ------------------------ ------------- ------------------------------- ----------- _ --------------- ----- ----- ----- r FINAL INSPECT --- -- --- :_ Date "� `1w3 .- 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 E.H.9 2M 1.67 Vanguard Press