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rvRvrrlLt U,)t: lall- _.�. ----------- ----------------- APPLICATION FOR SANITATION PERMIT Permit No. ----------------------------------------------------------- (Complete in Duplicate) -------------------------------- -------- ----------- --- — Th is Permit Ex Fires `Year From bate IsSuQd " "" a Date Issued _S____R_A_ E t_ 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_ _-: c Owner's Name_______--- Address.. iM - yi s ` `• Hlk ✓A-------1_- --------- -------------------------------------- Phone------------------------------------ r, ---------- ---------- 1 �R - _ + ---------------------------------- Yii><✓ , + - --------------------------- Contractor's Name------- _�- �_�./__ _.---------------------------------------------------------- �---------. Phone.._Other-----•�-------------•- Installation will serve: :Residence �, Apartment House ❑ Commercial ❑ Trailer Cour} Motel Number of living units: Number of bedrooms _� Number of baths _ Lot size .� t ❑ t Water SuPPIY= Public:system ❑ Community system ❑ Private [ � Depth to Water Table _ ft. V� Character of soil to a depth of 3 feet: !Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ( Hardpan Previous Application Made: (If yes,date_.____--. ._ ❑ t - --1 No [?� New Construction: Yes ® No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ` w L� Septic Tank: Distance from nearest well_'( !------Disfancy from foundation-__)-Q-4-----.---M�teria� _--_i�- ` - Q No, of compartments------�r-_----_---.-Size-___ _ - � i t , ;------- moi Liquid depth_..- �--------------Ca acct _ C_9 C-----I Disposal Field: Distance from nearest well-_4-Q--._-.Distart e. r o foundation.__- p y _{ `_-_----Distance to nearest lotNumber of lines_#.__t _----_--- -__ Lengthof each line" _ ;?__�` ` _-_-.Width of trench.___ _Q_ ____ _ __ ____T e of filter material ►¢ Dth of filter material_____}Qi�YP Total length- ' -- Seepage Pit: Distance to nearest:well_______ ______________Distance from foundation________.________._.Distance to nearest lot line_-.__._______.FNumber of pits.-- --r--------------Lining material-----;----_----_-:-----Size: Diameter------------------- _ -- - Depth--- ----- --- --------- - Cesspool: Distance from nearest well___._____._---_-Distance from foundation___________________ Lining material.._.__..__-.--.-_----__.- ---9---171 Size: Diameter )- -------- -------------- ----Depth-------------------•-------------- ----------------Liquid Capacityal Priv v�-�.� :,�,.-,�..- Y Distance from nearest well___________ ---------------- ---------------------Distance from n ares+ building____.__--.________.__________._____._. ❑ Distance to nearest lot line__.___-_.________________ -------------------- Remodeling and/or repairing (describe)__________ ------------------------ ---------------------------------------------- ----------------------------------- -------- ---------------------------------- ------------------- --------------------------------------------- -------------------I 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 a d}regulations of the San Joaquin Local Health District. r (Signed)--------------- -------------------- --- ------------------------------------------- ------ -----------------------------_----(Owner and/or Contractor) i BY:------------------------------------------------ -------------------------------------- - ---- ;------------------------ ------- -------------------------------------------------------:-------------- Title (Plot plan, showing size of lot, location'of system in relation to wells, buildings, etc.�can-be placed on reverse side). f' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED . ,BY REVIEWED BY _f � _----------- -- DATE-_- - /-A ---------- - --- DATE ----- BUILDING PERMIT ISSUED--'---=- ------------' r - ------------------- ------- ------------------------------------------ ------------------------------------ DATE.-----. --------------------------------------------------- : Alterations and/or recommendations:_-'------------------ f •--••---- 1 ------------------- - - - ._ . --------------------------- - --- ----------------------- ------------- -----•-•--------- -------- ----- --- - ---------------- -- -- - - -------- ----------- •- ------- - ----------------------------------------- ----------------------------- -------- ---------- FINAL INSPECTION BY;.......... y� ='r- Date _` 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 / i:'