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I - y1 I ILL VJC: ,- . - . _ _ ------ -------------'------------------.----------------- APPLICATION FOR SANITATION PERMIT Permit No. _ ._(_•_ I - ------------ -------------- --------- ------ (Complete in Duplicate) -"- --------------- --------------- ------------'-- --- This Permit Expires i 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 Nein described. This applicatio is made in co m liance with County Ordinance No..ra49— -' ��4-�esa ��jj �� Ps�t2�o►�- — rc�-�a � JOB ADDRESS AND LOCATION__ -t-4 1 ---------- Address3 1 l� Owner's Name---------- - ---------------------•-�-�=C'-�----•----�--Q �,�r-�.--- --�-�-7-v ' 1 ---------------- Phone_ ------ 7 -------- ----. Z .� Contractor's Name ------------------- s _NC'--------�-------- ------------------------------------- -� ='.._. Phone ------ -- -- - ------------- r Installation will serve: Residence Apartment House [❑ Commercial ❑ Trailer Court ❑ 'Motel ❑ Other Water Number of living units: __----__ Number of bedrooms _ ❑ ---_--- Number of baths --.___-- Lot size ---=,---_-��_C,(?9--Q��.-�,_�-- ---------- Supply: Public system ❑ Community system ❑ Private Depth to Waite f��yyTaQft- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Lda`m� Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes date_--._____ .__.-_..) No New Construction:Yes❑ No 01 FHA/VA: Yes ❑ No f TYPE OF INSTALLATION AND..SPECIFICATIONS: \,{ /, 11 (No septic tank or cesspool permitted if public sewer is available within 200feet.) _ 1 Septic Tank: Distance from nearest well-----------------Distance from foundation---_-_--_-__--. __.Material---------------___.__....______._-"_._...."----. ❑ No. of compartments-------------------------Size--------------------------------Liquid depth--------- --- Capacity -�e--1 r ------ --- p Y----------------------- V Disposal Field: Distance from nearest well_ / Distance from foundation_---/=' a__-"-._.Distance to nearest lot line______ .___.. Number of lines------------------ (-_.-- --Length of each line-----------!� _�- --"----Width of-trench.._-__' A Type of filter material-_ .- ------- Depth of filter material. - ..` --..._Total length-_-------� -- ___ _ V$ ----- - - ------------------ See a e Pit: Distance to nearest well_..__ - "__Distance.fro fo dation___ ---_.Distance to rieares# lot line____^________� Number of pits--------___l'-------Lining material__ -Size: Diameter.. P ----I" v e t� -------------- Cesspool: Dista"nce from nearest well---------------- Distance'from foundation__------------------Lining material_I-------.-.--_--__---_--__.__ ❑ Size: Diameter--------------------------------------Depth----------- ------ - _ .Liquid Capacity- --------------------------gals. Privy: Distance from nearest weH-------------------------------------------------Distance from nearest building - Distance to nearest lot line_________________________ " Remodeling and/or repairing (describe)-------------------kll 0 ------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------- 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 rules and regulations of the San Joaquin Local Health District. Signed)( g } S � -- ----------------------- (O er and/or Contractor) 8Y: --------- (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 APPLICATION ACCEPTED BY . - - ------------------------------------ - -----------I DATE--_--------- REVIEWEDBYD --- ------l- 5' - --- ------------- ---------- DATE PERMIT ISSUED-------•----- ---- - ------------------------ ------------ ----- ----- -------------- ---_._---- ------------------------ ---- DATE Alterations and/or recommendations:---_-._-----------_ ------------------------------------------ -- FINAL INSPECTION BY:_- _"--_- -- - / ff � 5 Date- SAN- ate 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 r. Tracy,California