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�OR OFFICE USE: -------------------------- P= S_ APPLICAT)ON 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, ._ ��-- / -apl ------------------------------- F JOB ADDRESS AND LOCATION' ----------- ----�---/. I Owner's Name---------- O ------- --- ----- ✓, .� --------------------- ---- Phone------------------------------------ Address------------------------- -------------------•-Address------------------------- ---- -,--f-- �/i�11 •------------------------------------------------------- -----•----•------------•----------- Contractor's Name---- Qw d ------------------ ---------------- -1 ----------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House E] Commercial ❑ Trailer Court ❑ Motel ❑J Other ❑ Number of living units: ---. Nu of bedrooms t Number of baths /_____- Lot size ___�� !-_ _ ----------------------- Water Supply: Public system Community system' ❑ Private ❑ Depth to Water Table ________ £t. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe j--+lardpan ❑ f Previous Application Made: [If yes,date--------------------} No [P-----New Construction: Yes [;;.-�o FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material ____....______..____..__..____-____-_----------- LLAXis �Jo. of compartments---- ---------------------Size-------------------------------Liquid depth-------------------------Capacity------------------- Disposal 'Field: / Distance from nearest well._.._—'-----Distance from foundation__,,�Q__1------Distance to nearest lot line.r/_______ ❑ umber of lines__-._______�-___- Length of each line___ (�..l'D_-----------_Width of trench ��-��_-____-----___._.. r r L f O �.-----.Total fen th600 ype of filter material___ _Z_ ---.Depth of filter material____ _ _ _______ g ______.___________________ Seepa e Pit: Distance to nearest well------.______.__.___Distance from foundation___________________Distance to nearest lot line----------------- O 1y cumber of pits----------------------Lining material----------.............Size: Diameter----------.............Dept h--------------------.------------ Cesspool: Distance from nearest well----------------- from foundation--------------------Liring material-.._____________________________ N ❑ Size: Diameter---- ------------------ - ----- ----Depth- ------------------------ -----------------Liquid Capacity---------•- ------------- -•gals. v Privy: Distance from nearest-well----------------____----------------------------:Distance from nearest building-----___------------------------......... ❑ Distance to nearest lot line-- ----- M�- -�4j-----�-------- --------- ------------------------------------- --------- ------------------------------------------------ Re deling an/�,��or�r pairing (describe) _-- --------Giw e ! Qd_-.C.t?I-' ��.� _� _ Ql� - - ---- ' 01 G l r� ,✓ � ------- J�_ 4� Rzp t- `` ----------------------- ----- I hereby certify that I have prepared this application and that+fie work will-be ddne in-accordarice *ith San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)----------------- 6 -----pli-7AZ ------------------ ------------------------------------------------- ------------------------(Owner and/or Contractor) By:----------------?;Fn L.0 --------------------------------------------------------------------(Title)--- �t`j�-------- --... .. -------------- (Plot plan, showing slocation of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY f APPLICATION ACCEPTED BY----------- ----------------------- REVIEWEDBY--------------------------------------------- -------------------------------------------------------------------------------- DATE------------------------------------ BUILDING PERMIT ISSUED--------------------------------------------------------------------------------2--------------------- DATE------------------------------------- - --------------------- Alterations and/or recommendations:--------------------------------------------------------- ------------------------------- ----------------------------------- Z44 /a- `S` ed.` ='�---- --- -.' -�-------------------- �` -- - - --.s.f FINAL INSPECTION BY:------- ----------- - -------- - Date------ f �� ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazeltan Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California