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FOR OFFICE USE: ------------- ------------------------------------ LA -------------------- LA APPLICATION FOR SANITATION PERMIT Permit No. - -------------- --------------------- ------------ (Complete in Duplicate) Date Issued --------------------------------------------------------- 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. JOB ADDRESS AND LOCATION--------- ----1.8 552 ---------�1R P 13 ------ 1/� ` -�A------- Owner's Name-------RA/ •-------KENA-ETO.----------RO-ROD-E-R-T-S------------------------------------------- Phone__—-3'_! sM:3_ . Address-------------------------. �----..o....A__5. 2...--- ?--------fi-)-RPaR_ -----ml ------------AM Contractors Name----f)1A �---•--•--------------•------------------------------------------------•-------------•- -•------------------ Phone................................... -- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [IOther ❑ J. i Number of living units: _�___-__ Number of bedrooms 3--- Number of baths Z Lot size ____e'o.___X_____li......0________________________ Water Supply: Public system ❑ Community system ❑ Private [Depth to Water Table -S- 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: Yes ❑ No [1 FHA/VA: Yes ®�No ❑ i 4WF_D DWQ-I-1 A1 C-- TYPE OF INSTALLATION AND SPECIFICATIONS: r^ (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well____'5__L-._-_Distant from foundation-____/f�--------Material___C�'NC_k'.F7-�.- __-_-_. No. of compartments-._. .-_-_--_---_-Size__-V��Q._X__57�Liquid p depth___Zstance �_Z__.____Capacity_../_2-p0_____ 1 Disposal Field: Distance from nearest well -_._-Distance from foundation------ to nearest lot line... Number of lines--------Z..._._._.___._._.._Length of each line_75_(______i`______-Width of trench_..__2_T,-�.�.---_._.�___.._ Type of filter mate ria l__R0_C_K___-Depth of filter materiaL___1�_________..Total length________________-_/.70-____--_-_ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line-----.-___-__-.-- ❑ Number of pits---_------------------Lining material---------------------..Size: Diameter---------------.-------Depth----------------_---------------- Cesspool: ._,.,___ --__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):----- ----------------------------------------------------------------------------•-- -----------------------•----------------------- •-------- -------------------------------•-------- ---------------------------------------------------------------------•----------------------------------------------------------------------------------------.-=------------------- -------------------------------------------------------------•----------------------------------------------------------------------------•-----------------------------------------------•---------------------------- --------------------------------------- ----------------•-------------------------------------•----------------------------------------------------------------- ---- --- I hereby certify that 1 have prepared 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. (Signed)._A,f --------___-_---------------- • _..____.(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). FORD ARTMENT USE ONLY APPLICATION ACCEPTED BY------ --------------------------------------------------------- DATE--------- z '� ----------------------- REVIEWEDBY--------------------------------------------------------------------------- ------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE----------------------------- ---------------- -------------- Alterations and/or recommendations:------ ---------------- ------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------- --------------------------------------------------- ------- ----------------------------- ----------------- ------------------------------------------------- ----------------------------- ----------------------------------------- ------ - ------------------ ---------- --- FINAL INSP N 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.C C.