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,- FOR OFFICE USE: . �/ -0121 ------------ ----------- 14.r o 0 ------� - ---------'------- -- ------ APPLICATION FOR SANITATION PERMIT Permit No. jf y�/Z 9 (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 permit to construct and inst1,0 a work I�er�idescrbed. This application,.is._maden_co.mpliance with County Ordinance No. 549. 'J'''AI)DRESS AND' 9CA iON-- Owners Name ----- /. ------------------ ------ Phone------------------------------------ Address --------------------- - -----------------�- - ---------------�- •----------- Address------•------------- Contractor's Name •---------------------------------------------- -------------- Phone.------.-------._ Installation will serve: Residence ❑K`X'partment House [❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _f____ Number of bedrooms -P4--.- Number of baths --A-- Lot size Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Tablef�. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [ �Clay ❑ Adobe ❑ Hardpan [] Previous Application Made: (If yes,date--------------- ----) No [K New Construction: Yes Z?'11'o ❑ FHA/VA: Yes Z4/No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: [Na septic tank or cesspool permitted if public sewer is#ante fromlefpu within 200 feet.) Septic Tank-'�, p u., Distance from nearest w � a u �LNo. of compartments_._ ___.__- 5ize_ti1 ._ _ _ � squid depth- ,_ '--------------------Capacity/_ - n-------- N 1 f Disposal Field: Distance from nearest well--_�?tV -_Distance from fou ndation----1,�:._.---.Distance to nearest lot line__u _______.. N- ---------- ------------Length of each line------ -- -- ____ _ -�V Number of lines-_-_____1 ��---- _-- _:---Width of trench._�-------------- , Depth of filter material____. __ __6� f Type of filter material_______-__- f /r `__.Total length ` : _-------------- Type ___ ___ --_- i Seepage #: Distance to nearest well___ p Distance fr m fo ndation---/_L�-------.Da'st nce to nearest lot line__1 ________' Number of its___ -`____ Linin material___ ___1— ' p / ..—Lining. _--.Size: Diameter__-- -__._--- Cesspool: Distance from nearest well-----------------Distance from foundation------------.-------Lining material------------------- __.______-_____.; r ❑ Size: Diameter-------------------------------------Depth-------------------------- --- ---------------------Liquid Capacity-. -- -------------------.gals'.: l Privy: Distance from nearest well---------------------------_---------------------Distance from nearest building-__._________-________-_________..-__-._. i ❑ Distance to nearest lot line--------------------------------------------- -------__-- ------------------------------ Remodeling and/or repairing fdescrifie):------------Aflk/ =Q -•---------------- F - �. -- ----------------------------------------------------------------- ----- -— ,�_ r_ ---------------- --�--- �__ ------------------------------------- ---------------------------------------------------------------------•----------------------------------------------------------------------------------- ----------------------:----- � --------------------------------------------------------------------------• - ----------------------------------------------------------------------------------------------------------------------------- ------------- . I 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. {Si'ned2% ------- --- .9, { ------ ( axd r Contract BY:--------------- ----------------------------------------------- - ------------------------ITi+1e� o or d ----------------------------- (Plot plan, showing size of lot, location of sys+ in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ � — DATE /` I . REVIEWEDBY ------------------------------ ------ ------- --------------------------------------------- --------------- DATE BUILDING PERMIT ISSUED--------------_------------ DATE--- Altera+i ns and/or recomrpondafions:__________ ____ __ -� - C . :� ------- - . - _ = �_ = - �-�` --------I ` � ryr �- -------- � �� ------ -=------ ------- F1NAL INSPECTION BY:-,-- ------------ - --- -------- Date---------------/_--------- _�® �/. -.. AN JOAQUIN-LOCAL-HEALTH DISTRICT 1601 E.Hazelton Ave. y 00 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California