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FOR OFFICE USE: ---------------------------------------- - ----------- ��-_________ APPLICATION FOR SANITATION PERMIT Permit No. _ 5. _21' ------------- ------- ----------------- ------------- - ------- Date Issued -- (Complete in Duplicate) d /�c -___------_-___---_-_-__------_--__-_-____--_-_- --- This Permit Expires 1 Year From Date Issued 7 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work�et�i e i This application is made in compliance with/County Ordinance No. 549. JOB ADDRESS AND LOCATION_ �___l��-_ ' 1 r 4 4'� ( '2 7 �7 Owner's Name-- f-------- 8 'Di ✓' " a ------------ Phoner�93._--ZP�.�!--_ Address..[__ • ..... . ( ® � I °� [ /' �� // C-!q....-►--C_�=1_-rft--------------- ---- Contractor's Name-:--- _ QAW_E..---_--------------------------- ---------------- Phon ... ..._'....... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/__ Number of bedrooms-'Z-_ Number of baths _f___ Lot size __-140'a.&1:e---- ----- ------------------ Water Supply: Public system ❑ Community system ❑ Private [!�Depth to Water Table .4-- 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 FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T Distance from nearest well___ -----Distance yfrom foundation-----t�_--------Mat rial______C00CR T"E____-___- p No. of compartments____2_:-_____.--.-_Size._ __�1--�0_X_ -_Liquid depth__- ,�Z-__-_-__-Capacity___ .Q��___ Disposal ield: Distance from nearest well__ -----Distance from foundation---ZQ..........Distance to nearest lot line__________ Number of lines----------1----------------------Length of each line-------/ Q------------Width of trench_-_--W_.!f-_-________-... %a Type of filter material_BOCK-_-Depth of filter material-___ -----Total length--------1Q_®-`_--_________-.__ � Seepage Pit: Distance to nearest well----- ----------------Distance from foundation--------------------Distance to nearest lot line_____-___________ d ❑ Number of pits-------___.------ __Lining material_.__. ---_------------Size: Diameter_------------.-------Depth---______________________--_--_ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------._____-___________. D ❑ 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):--------(SENF04-------- ------5/v M_---------------------------------------------------- -------------------------------------------- --------•-------------•-------------------------------------------------------------------- -------------------•-•---------------------------------------------------------------------------------------- ----- -- ---------------------- -----------------------------------------------------------------------------•---------------------------------------••--------------------------------------------- ------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. �'-=--_'� ----- - (Owner and/or Contractor) (Signed) 'F /k ��y �- By:-------------------------------------------------------------------------- ---------------------------------------------------------(Title)-------__------------------------------ ------ ------ (Plot plan, showing size of lot, location of system in relation to Z IIs, buildings, etc., can be placed on reverse side). FOR DIEPAATMENT USE ONLY APPLICATION ACCEPTED BY-------T1R--CL--------- -------------- ------------------------------------------ DATE----------- +-------------- REVIEWEDBY--------------------------------- ------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------ ---------------------_----- Alterationsand/or recommendations------------------------------------------------------------------------------------------------------------------------------------------------------------ -------------- ------------------------------------------------------ ----------------------•------------------------------------ -------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------- )/ FINAL INSPECTIOtd-�B _ - --- ------------- - - 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. _