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FOR OFFICE USE: " ---------------Wn------------- --------4..------- �'" - APPLICATION FOR SANITATION PERMIT Permit No. ---------------------------------------.• -- ----- (Complele in Duplicate) S Date I % This Permit Expires i Year From Date Issued sued 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. /_ '111T 21 4_ -7 2 4& JOB ADDRESS AND 21 4_ -----------16----------------- ------------------ -r-H KQ_T>----- Owner's Name--------------FAAWK....^./ ant _r r --------------------------------------------------------------- Phone---------------------------------- Address ! 57C --------------------------------------------------------------------------- -------------------- Contractor's Name--------1OVV/V5;_1FZ----------------------------------------------------------------------------------------------------------- Phone---------------- ----------------- Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __I_.___ Number of bedrooms 3... Number of baths --/-- Lot size --- __________ ___________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table __ _ ft. Character of soil to a depth of 3 feet: Sand [) Gravel ❑ Sandy Loam RrClay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date____________________) No 5R�` New Construction: Yes [Z--No ❑ FMA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r. ,�/ V' Septic Tank: Distance from nearest well---�_�'-5�'..__Distance from foundation____��___----Material-RE- P—WOOD__.__._____--- N 2t� No, of compartments--------. -----------Size__ _ _ __ -----Liquid depth__.�'� _________ Capacity___. � _-__.. Disposal Field: Distance from nearest well-C,W___Distance from foundst'on___/-_-._._.__.Distance to nearest lot line_-----.. � -— "Number of lines________ ______ ____ :.-------Length of each line__ 2C �� c Type of filter mate rial ---Depth of filter ma -_____________Total length_._._________ ___ T Seepage Pit: Distance to 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--------------- -----------.--___--_- ❑ Size: Diameter------------------------------------.Depth-.-------------------------------------------------Liquid Capacity----------------------------gals. {- Privy: Distance from nearest well-------------------------------------------------Distance from nearest building...______..____________________._._..____. ❑ Distance to nearest lot line- ------------------------------ ----------- --------------------------------------------------------------------------------------- --- Remodeling -Remodeling and/or repairing (describe):------ --------------------------------------------------------------------------------------------------------------------------- �b� r ---------------------------------------•---------------------------------------•----------------------------------------------------------•--•----•------------------------------------------------------- -------------- ------------------------------ ---------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------ --------------- 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. 1 (Signed)- = -----C4--- n J_ - ----------------------------------- ---- - ------ -----------------(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 DEPARTMENT USE ONLY, r� APPLICATION ACCEPTED BY--- - C1 ------------- --------------------------- -- DATE...... .S-' 5-�----1---------------------- REVIEWEDBY-------------------------------- ------ ----- --------- ----------------- --------------------------------------- DATE------------------------------ BUILDING PERMIT ISSUED---------- --------------------------------------------- ------------------------------- --------- DATE--------------------------------------------- ------------ -- Alterations and/or recommendations:-------Nin-TE _____ _.______________ -- ----------------------------•------------------------------------------------------------------------------..-----------------------------------------•--•------------------------------ ------ ------------------- FINAL INSPECTIO ---- -1- Date-------------� .-.LAS-------�---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haielfon Ave. 300 Wes!Oak Street 124 Sycamore Street 205 West 91h Street +t3 Stockton,California Lodi,California Manteca,California Tracy,California F.R CC.