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� FOR OFFICE USE: --- - 1f------ 3r�-------- APPLICATION FOR SANITATION PERMIT Permit No. r -------------- ---- ----- ----------- ----- ------ --------------------------- (Complete in Duplicate) Date Issued f ------- This _ -This Permit Expires 1 Year From Date Issued s• ftr 2 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the wor e�rein escr ed. This a0plication is made in compliance with County Ordinance No. 549. :'IT-WBDDRESS AND LOCATION..-_. tom/ ---C��%.... l-VO Phone------------------------------•---- Owner's Name-------- tee,4----- -- --------------- �.? 421- ---- ------ --------------------------- Address----------• ---- --- - -- - Contractor's Name-------- --- •------- •----•--- Phone--------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of baths _ ____ Lot size -(5`-- -- ------------------------ Number of living units: _/_. Number of bedrooms c Water Supply: Public system El system [I Private �pth to Water Table �f+'" Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay. ❑ Adobe g3o'lTardpan ❑ Previous Application Made: (If yes,date-".-- --------------) No R`lNew Construction: Yes to ❑ FHA/VA: Yes 94—NO NO ❑ i TYPE OF INSTALLATION AND SPECIFICATIONS: .� (No septic tank or cesspool permitted if public sewer is availebie within 200 feet.} r e.-.. _ �D---- Materi !` .`, - '- - -------'j Septic Tan _ Distance from nearest well_..__.Dis#ante from fo ndation__ P - Capacity of compartments_.- Sizes �� I- e%i uid depth...._.'___...__-_.- - P Y ��_,._.....Distance•to nearest lot line--- I pisposaI Field: Distance from nearest well -.-_Distance}from foundation._ __ "- Y Width of trench_1Z__1---------------- --------j . l Number of lines-----�__-_�fes_._ ______ Length,bf each line--_ - �----= � I Type orr filter materii jliC�."- Depth of filter',material___ ----------Total leng --------------- -� Distance rom'fo dation___ _ ---Distan e to`tnearest lot lire--4�------- Seepage Pit: Distance to nearest well-__, �a-- - p – /ly -1 Number of pits--_-p -____--_-.Lining material/ -Size: Diameter__S_9----- ---r eptn Cess Distance from nearest well..... .--------Distance from foundation.-'"_ - .Lining material--.------_---__----__.------_------ * Li uid Capacity _gals ❑ Size: Diameter--------------------------- -----.Depth--------------------------------.:.--- ------ :>= G P Y Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-F__-.---.--_.--____.__.__-------------- ❑ Distance to nearest lot line------ ---------- -- ---------------------------------------------------------- t ;and o'r re airin describe ------------ ----- -------------------------- -------- Remodeling / P g �• } i 1 ----------------r t ------------------------------------ --------- ------------------------------------------------ --------------------------------------------------------------------------------------------- ----------- 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, and rul s and regulations of the San Joaquin Local Health District. (� (Signed) - -- --- -------------------------- ----------- (� Contractor) V By:----------------- ------------------------------------ ------ - - ---------- (Ti#Ie) �1•�!'/� k (Plot plan,.showing size of lot, location of sys to relation to wells, buildings, etc., can be pieced on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------ ------�-- --------------------- -- - -------------------------------------- DATE ?G G - REVIEWEDBY---------------------------------- --------------- --------- ------------------------------------------------------------- DATE------------------------------ ------------------------- ' BUILDING PERMIT ISSUED----------�1 116 -- DATE ---------- --- - ------- ---------------------------- ------------------ ---------- Alterations and/or recommendstions:______."�.��-------C-.l� r '� -------- -------- •--------------------- ------------------------------ --------------------------- ----------------- J��` ---- Date-------- -- -- - FINAL INSPECTION BY:------------ .... �:..... •- -- �:- -- - ,� k SAN JOAQUIN LOCAL HEALTH DISTRICT 124 Sycamore Street 205 West 9th S)reet- 11601 E.Hazelton Ave. 300 West Oak Street Stockton,California Lodi,California ` Manteca,California Tracy,California r•.a.co. F{ t ,