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FOR OFFICE USE --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. _ --�___-_. ------------------------ ---------- -------------- ------ (Complete in Duplicate) -- This Permit Expires 1 Year From Date Issued Date Issued ___._ .. X5-310 -0/ 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 AN L CA O �1 �ic� Zrr..-_- C - ` f - * • t �� ��; f� r Owner's Name- -Arz, - ----- �C_! '.f� Z' Ii . �--------- - -------- -------------- Ph e----••-------------------------•---- ------------------ s .• Address -1��-------- --------'/--� 74 --------------- 'rte' - ------------- ---- r , - Contractor's Name-----------�. ...... ---------------•--•--- Phone----.... ---------------- Cw Installation will serve: Residence Apartment House ❑ Commercial ❑ .Trailer Court [I Motel E] Other E]Number of living units: _1--- Number of bedrooms --- Number of baths -=. _ of size .-.- - .�-- ------------ 0 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 ❑ Clay Loam Clay E] Adobe E] Hardpan Previous Application Made: (If yes,date____________________) No New Construction: Yes No E] FHA VA: Yes ( No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (INo septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well---- O Distance from foundation....].- -___.MatePa ----- ---- --_ 0 __-. XNo. of compartments------�1-----_.--Size------ ,�* 42_--------Liquid dept,-_'A-- - p al Field: Distance from near t weft---q ... Distance from foundati -----.Distance to nearest lot li e__ -pis Number of line s_-_. - --Length of each lin --_l�r �' o tench---. /� g - W-- �dth �t ------- -•----... Type of filter material--, - -.-*Z --._-Depth of filter material.-�._ -_-------Total length----------- - -----------------_ Seepage; Pit: Distance to nearest well.-.-------------------Distance from foundation--------------------Distance to neo es to line----------------- ❑ Number of ptts----------------------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 and/or repairing (describe)---------------------- -------------------------------------------------------------------------•--------------•-------•-------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------- ------------- ------•----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------- --------------------------------------------------- -------------------- ----------------------------------- --•-----------------------------•------------------------------------------------------------------------------------------------------------------------- --------------- 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, andrulesand regulations of the San Joaquin Local Health District. ISi ned "z -----------------------(Owner and/or Contractor) 9 )---- ---------------------------------------------------------------Z� Ely:-----------------------------------------------------------------------------------------------------------------------------------(Title)------- - --- ----------- (Plot plain, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------- ----------------------------------------------------------- ------- DATE------------------------------------------ ----------------- REVIEWED BY--------------------------------------- -------------- -- ------------------- ------- ----------------- :DATE---- �-� BUILDING PERMIT ISSUED------------------------•--------- ------------------------------------------ ---------------------- DAT E-----�--fl-------r Alterationsand/or recommendations:--------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------•---------- ----------I--------------------------------------------- ------------------------------------------------------------------------------------------------------- -----•--------------•-------------------•-•-•--------------- ------------- ---------•-------------------------------• --------------------------------------------------------------------------- ----------------------------------------------------------------------------------------- •----------------------------------------•----------------------------------------M--------------------------- FINAL. --------------------FINAL. INSPECTION BY--------------- .- f C�'Q/I Date- -----------� J '---�---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California Es 9 REv75Eo a-59 3M 3-'63 r.F.ra. _ ..