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FOR OFFICE USE: IN p4 -------------------- _ _ /�.� ----------------------- ._._.__..__.._ _____-.----�M--- APPLICATION FOR SANITATION PERMIT Permit No. ----------- .i--- (Complete in Duplicate) ------------------ -- - -- - -- -------------- �1.-- This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made o 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. 5 JOB ADDRESS AN LOCA�TIO �1. ��r ' = �fr--------------------------------------- Owner s Name---.��-�Y�-- --- ---- - --- ---- ne--------------------------------•--- - - --- -- ------------------------------------------------ Address----- --------- -------------------- ----.... Contractor's Name— ------ :.i �-- - -- -- ------ -•--------------- - ------ Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ I Number of living units: __l__ Number of�bedrooms.=�_._ Number of baths /-___ Lot size __7o � f� __________________________ de Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table `/Qft. Character of soil to a depth Iof 3,feet: Sand E] Gravel E] Sandy Loam R__151ay Loam E] Clay E] Adobe E] Hardpan F1Previous Application Made: (If yes,date---------------------) No New Construction: Yes ❑ No FHA/VA: Yes ❑ No2D_�— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank-or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well........ "------Distance from foundation__�!P_--------Matezl__101 �'4.40e / ---------- No. of compartments-----A--------____---Size_O,Y�------�1l3Liquid Disposal Field: Distancej,�from nearest well.................Distance.from foundation--------------------Distance to nearest lot line__________..__-•. ❑ Number of lines----------------------- ------Length of each line------------------------------Width of trench------------------------------------ Type of filter material_____________`___________Depth of filter material-----------------------Total length___.--__-________-_____________.________ Seepage Pit: Distanceto nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_____.____.._____ ❑ Number.of pits----------------------Lining material---------- -------.----Size: Diameter-----------------------Depth--------------------------------- ` Cesspool: Distance from nearest well__._------------Distance from foundation--------------------Lining material---------------.------._-__.______.._.El � !N Size: Diameter--- ----------------------Depth--------------- ----- ---- -----------------. Liquid Capacity gals. Privy: Distance:, nearest well-l.'-----------------_------------------------Distance from nearest building__________-__-__-----_---------_------ ❑ --------- -„ .� Distance!�to nearest lot line--`---------------------------------------- ------------------------- . -------------------------------------------------------------------- !� • ------ - r--------------------- - Remodeling and/or repairing (describe}:____--___ .C,_ � � �S _ ---•--------------------------- -----------•----------------------•-------•--------•-------------- ----------- ----------------------------------- -- ---------- ------------- -------------------------------- --------------- ----------------------------------------------------------------- lF .- I hereby certify that I have prepared this application and that the work will be dans in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)---------------------- �- x Contractor fry --�- r -- ---- -- -- ------------------- Title___ _ (Plot plan, showing size of lot, location of system in rel to wells buildings, etc., can be placed on reverse side). (�. FOR DEPARTMENT USE ONLY I, w� } APPLICATION ACCEPTED BY• .._._ __ _____________ DATE---- _. REVIEWEDBY------------------------il----------- -------- --------------------- ------------------------------------------- -------- DATE------------------------------------------------------------ 4 BUILDING PERMIT ISSUED--11--------------- - .. DATE-------------------------------------- ------ Alterations -------------- ------ Alterations and/or recommen11 dations:------------------------------------ ------ - ----------------------------------------------------------------------------------------------•------------- ------------------------------------------------ ----------------------------------------------------------------------------------------------------------:--------- -------------•- ------------------------------------- IM. ------------------------------------------------ il, --- ---- ------------------------------------------------------------------------------------ ------------------------------------ --- -- ---------------------------------- ----- --------------------- ------------ ----------------------------------------------- ----------------- ---------=--- ----------- - ---- ------------ ----------------------------- IJ -� FINAL INSPECTION BY:.-�- Date_ _Z-2 Dafie -Z--2 ----------- - � ------------------ -------- i I 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.0 O.