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s /�,� FOR OFFICE USE- -- --- -- ----------------------------------------------- APPLICATION FOR--5ANITATION PERMIT Permit No. ...1.-- . .: ..__. -------------------------------------- -------- [Complete in Duplicate) /G This Permit-Expires 1 Year From Date Issued ©ate 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. - - --- ---------- JOB ADDRESS AND LOCATION--------1��n-`3-��-----------�( -r�,oi"Q'------ -------'�---- 2�--------------------------------------- - - - Owner's Name----------------------------------------W.—.-r A------ v `Q (.e3 F} --�-}----- = ----------=---------- Phone--4�-3.- 7 � Address.. � 3 � e.-t�_� f L rx�---------------------•-•----------....--•-------------------------------• . Contractor's Name ---------2.0 i4 -4------7iJ G------------------------------------------------------------ Phone_e _6-- I, Installation will serve: Residence Q' Apartment House ❑. Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ It Number of living units: _-�-_--- Number of bedrooms --:Number of baths.--)---- Lot size _-1,---K.t.- .O -------------------------------- Water Supply: Public system 5� Community system ❑ Private ❑ Depth to Water TablesSQ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy.FLoam ❑ Clay Loam,( Clay ❑ Adobe ❑ Hardpan ❑ I Previous Application Made: [If yes,date--------------------} Nox New Construction: Yes E] No FHA/VA: Yes ❑ Nom] 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-------------------.Material---------.-.---.------.--..----------.-.--.-----. ❑ No. of compartments----- - ---- -----Size--------------------------------Liquid depth--------------------------Capacity---------------------- Disposal Field: Distance from nearest well----_------ r Distance from foundation---lC:_r-------Distance to nearest lot line_1 ........ Number of lines------------/--------------------Length of each line-------Z;--------------Width of trench_______- ------------------------ ky Type of filter material-_-. .. oc� -_Depth of filter material-----t-a.- .`�----Total length_:_--- -.5�_______________--_. Seepage Pit: Distance to nearest welt__------- -----------Distance from foundation-----J0---------Distance to nearest lot line -------- V1 xNumber of pits____----A...........Lining material---S_ S ize: Diameter...... (-------------- V1 Cesspool: Distance from nearest well-----------------Distance from foundation............1t......Lining material------------------------------------- 0 Size: Diameter---------------------------- - ------ Depth- ------Liquid Capacity----------------------------gals. Privy: Distance from nearest well----___------- -----.----------------------------Distance from nearest building-------------------------------.---------. A ❑ Distance to nearest lot line----------------------------------------------- --------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe}:__-.---�- a ___'Ti---- -x-S__ --------oe! ,�------ ' -----------•---• ----------•------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------•---------------------------•----------------------------------=----------------------------------------------------------•-•---------------- ---------------------------------------------------- �+ ----------------------------------------------------------------- QW 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 re ulations of the San Joaquin Local Health District. 4 (Signed) [T -L _�----..---_--.-..----- Owner and/or Contractor By:--------------------•.----------------------------- �-` -------------------- -(Title)----- ---- ------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEP RTMEN USE ONLY APPLICATION ACCEPTED BY ------------------------------ DATE----- - 1 . REVIEWEDBY ------------------------------------------------------------------- DATE-------- -------- ------------------------------------------ BUILDING PERMIT ISSUED--------------------------------------------- ----- p ---------------- DATE------------------------------------------------------------- Alterations and/or recommendations:- - - - - ��---- - -- -------- ------- -------------- -------- - --------------------------------- -----•------------------------------------------------------------------------- -------- - ---•------------------------------ -- ---------------------------------- -------------------------------------------------------------------------------------------- -------------------------------- ---------- --------- --- ------------------- ---------- ---- ---- -.--------- ----------- ------•------------------------------------------- ------------------------------ .��FINAL INSPECTION BY:----�- .-�--- ------------- Date--------------- --------- ---- -- ---- - ---- ---------------------------- SAN J QUIN 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 �` xL