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FOR OFFICE USE: 777-__17 l J c?---------- R Permit No. -C.7- QcS, APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Date Issued _17-------------------------------------- -- ------ ------ - -- - -This Permit Expires 1 Year From Date Issue ribed. Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein desc This application is made in compliance with County Or inance No. 549. JOB ADDRESS AN LOCATION--__ ----- -- ---------------•----------------------- Phone----- -----------------•------------ Owner-s Name..............-------------- •-•--- Address- --S ".— -••-------------------------------• ------------------•------------------------------------------------------------------------------------- ------------------------ a._ , Phone ------------------------ Contractor's Name-- -- Installation will serve: ,'Residence nApartment House4❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __�____ Number of bedrooms _�- Number of baths -1----- Lot size ----/-qd-'-�-f_0------------------------ ------------ Water Supply: Public system Community system ❑ Private ❑ Depth to Wafter Table _f _ ft. m Adobe [Hardpan ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel F1 Sandy Loam El Clay Loa ❑ Clay ❑ Previous Application Made: (if yes,date--------------------) No [ New Construction: Yes ❑ No FHA/VA: Yes ❑ No [!'-- TYPE OF INSTALLATION AND SPECIFICATIONS: J (No septic tank or cesspool permitted if public sewer is availabke within Z00 feet.} Septi T nk7 - Distance from nearest well_________________Distance from foundation-,__._._..--______-Material..-___--___---__--____-._____--___----_-.------ No. of compartments------------- -----------Size--------------------- ----------Liquid depth.-------------------- ----Capacity---------- --4---- Disposal Wil Distance from nearest well.... .........Distance from foundation_ j' Distance to nearest lot line-------_.___. Length of each line___.-��---------- Width of trench._ _�---------------------- Number of lines------I--------------------------- 9 � Type of filter material_-_ FVCIA------Depth of filter material__`-- --------Total length-----c�--a--------- 5eep�.age.Pit: Distance to nearIf est well.___"^___--..._-_Distance from foundation___/A_c___.___ Distance to nearest lot line__--------- Ln --Lining material---k 7pGfi---Size: Diameter------- - ------Depth_._._- i ----------------- Number of pits---------------------- Distance from nearest well_________________Distance from foundation.---------------- -.Lining material-------_._____--___-_.._--_____--- Li uid Capacity _____________gals. ❑ ,.� Size: Diameter----- -------------- ---- Depth q p Y Privy: Distance from nearest well-------------------------- - --------------Distance from nearest building----._-___---_._-_.._------------------- �,► ❑ ------ -------- ----------- -------------------------------------- Distance to nearest lot line_____________________ - Remodeling and/or repairing (describe):.._-----_-------------------- ---- ------- ---------------------------------------------------------------------------------------------------- ------------••---•-- ---------------------- ---- ------------------------------------------------------------------------ ---------------------------------- - ------------------------------------------------------- ------- -------------------------------------------------------------------------------------------------- done I-hereb certify that and have es prepared this ap plication the San Joaquin hLocal Healthe work eDistr ctn accordance with San Joaquin County ordinances. State (Signed) . . ns . -- - . . --............... - ---------------------[Owner and/or Contractor) I -------- --- ......- -------- ( (Tit eP SY (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be laced on reverse side). f § FOR DEPARTMENT USE ONLY ATE------- ------------------- APPLICATION ACCEPTED BY----------- - D `��-•--- ------ ----------------------------------- ----------- ---- REVIEWED BY------------- ------------- --- --- ----- --- ------- --------- -- ---- ----- -- -------------- --- --------- DATE I BUILDING PERMIT ISSUED--------------------------------------------------------------–-------- ------- ---------- --------- - -------- --------- ------ ----------- --------- - ------ --------- DATE--------- -------- --------------------------------------- ( Alterations and/or recommendations:____-- --------------- ---------------•-- - k ------------------------ - ---------- ------------------------ --- ------------- ---- ------------------------ ------------------------------------------------------------------------ �j�� 7 G Date_. /-`- �� ' - FINAL INSPECTION BY:-__... ---"- .--�--- - ------ SAN JOAQUIN LOCAL HEALTH DISTRICT • 16o1 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California