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AOR OFFICE USE: ----------------- _ ------------ -- -- ----------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .._ � (Complete in Duplicate) --------------------- -------------- ----- ------ - --- This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a per it to construct and install the work herein described. This application is pliance with County Or inanc Nq. ,�}9. JOB ADDRES A ,r_ -- ----•- ------ - ----•------_-- •-� ----4--------------------- Owner's Nam R ---------- .. ---------- ----- --- Phone--- ------ --- -- Addre 424113 .---- -� --- -- ... ----------- ----- ------ -------- ---------- Contractor's Nam Installation will serve: Residence ®partme --- ------------I------ ----_. Phone -� .7 ----- nt House p Commercial ❑ Trailer Court ❑ Mote! ❑ Other ❑ Number of living units: _/__- 'Number of bedroom._ mber of baths _1� � f I - --- Lot size - - -----------�I�-1-�-- -�--------- ----- ' Water Supply: Public system ❑ Community system Private ❑ Depth to W r able --- ---- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam iay Loam ❑ Adobe ❑ Hardpan ❑ k Previous Application Made: (If yes,date._________--------,) No ❑ New Construction: Yes No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATe1ONS (No-septicTtankVor..cesspoo!_permi#ted,ierjis_.availabfe within 200 feet.) —ZE01 Septi an Distance from nearest welista e fro fou at' n___ ______.Materil.___..._ _ ._7 tNo. of compartments.. ize _ Liquid deptll,S---4 -__-_----Capacity_____ ----- --- D;spo al Field: Distance from nea t welistance from foundat;on___ 0 ` Distance to nearest lot I; e ---------- Number of lines______ __ ___ _ _ _______ Length of each line-r_ ,f{_3J-_Width of trench_ <f----_ Type of filter mater' ______Depth of filter material------ �---__Total length___.---.__________._---/��- Seepage Pit: Distance to nearest wail________________ _____Distance from foundation-----------.--------Distance to nearest lot line----------------- ty ❑ Number of pits--1-------------------Lini material---------- ------------Size: Diameter-----1---------- ---Depth--------------------------_ Cesspool: Distance from nearest well-----------------Distance from foundation.--- .___________.Lining material__._-_-....___.___._ 1 ----------- ❑ Size: Diameter ------ ----------------------- Depth-------------------------------------------- - - ---Liquid Capacity ------------ ---------gals. Privy: Distance from nearest well_________________ -______Distance from nearest❑ building----------------------------------------- i Distance to nearest lot line-----------------------------------------------•-----_- Remodeling and/or repairing (describe)=------------------------------------------------------------- ------------•------------------------ -------------------------------------------------------------- 1 --------------------------------------------------------------------------------------------- ----------------------------------------------------------- ------------------------------------------- -- - I hereby cer f hat I have repared this application and t the work will be done in accordance with San Joaquin County ordinances, Stat I s, rules d regu tions of the San oaq ' Lo Health District. i �` � # (Signed)--------------------- - + �. • ------ J ----------- or Contractor) Y•- -J-=-4_. -.----= --------- ---=_- - Itle) F- - (Plot plan, showing size of lot,'location of system in relafion to ells, buildings, etc can >5e placed on reverse side). 1 I FOR DEPARTMENT USE ONLY a APPLICATION ACCEPTED BY.... f- '`1� --------------------------------------------------------------------- DATE------ `G' REVIEWEDBY ------------ ----------------------------------------------------------- DATE BUILDING PERMIT ISSUED-----------------f----------------- ------------------------------------ ------------------- --------- DATE. - -Alterations and/or recommendations__________________ -----------------------------------------------------------------------------•-------•------------•----- --------------------------------------------------------------- --------------------------- --------------------------- --------------------------- - - -•--------------------------------------- FINAL iNSPEC BY:_ -- ---- Date--------- L-r---`-2215, ^ ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxellon Ave. ; 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California