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FOR OFFICE USE: --------------------------------------------•--- APPLICATION FOR SANITATION PERMIT Permit No. -•---- -- ------------------.,.......--------- t (Complete in Duplicate) Date Issued This Permit Expires 1 Year From DateIssued Application is hereby made to the San Joaquin Local Health District for a permit to consk i Itt��gd- N the v�Jo�k herein des ribed. This application is made in compliance with C my Ordinance No. 549. e637 o�0/ JOB ADDRESS AND LOCATION---- = --------- .....=g'-`v......---.W� �..�../... ... eo Owner's Name ...... . ....... Phone. ._..�._, 'f_�,rk_,Q Address.------------_- = �A� ,1 -� _a,...� ----------------.- .------------ �L! Contractor's Name_. ........_._ Phon Installation will serve: ' Residence ❑ ,Apa ent House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units. I... Number of bedrooms eZ.. Number of baths 1___ Lot size _ _______________________________ Water Supply: Public system ❑ Community system ❑ Private [Depth to Water Table _d._± ft. Character of soil to a depth of 3 feet. Sand ❑ Gravel ❑ - Sandy Loam❑ Clay Loam ) Clay ❑ Adobe❑ . Hardpan Previous Application Made: 11f yes,date-----------------__I No .=New Construction: -Yes No ❑ FHA/VA: Yes I] No ❑ TYPE OF INSTALLATION'AND SPECIFICATIONS: _lim(No septic.tank•or cesspool perri�if public sewer`is available within-200 feet.). ._ - p r_-� _ O D e- nce from foundation-_J49 -.- ---__-- p -- - -`:-- ata 4 U No. of'com artmen#F,3 _.j z .�-�-`�-�'•_e_...__.Liquid depth_...._`---------------Capacity... Septic 7a Distance from nearest well... .__ -__ rbi f well__,.__. _. Di Disposal 1d: Distance from nearest � A__.... stance from foundation._, 4.�..._____Distance to nearest lot line___.._ [ � ' I% �_____-r� -:__-_-Length of each line___ f1PWidth of trench.....2..�__., _ ubof.filter math cial. x% i________._Depth of filter material.._��_____________Total length-------- '..�o�----------------- Type See age Pit: Distance to nearest welC._�._ __.__.__D•i:stance from foundation____!_'_...--.Qistance to nearest to im f_____ .I j i _6 ,,,, ''��gg ------ Number of pits--�------•---•-." --Lining material.�_�!!_�_____---Size: Diameter__.s�--.3-f-------Deptn__. ---------------- �b Cesspool: Distance from nearest well.....:.----------Distance from foundation._."________________Lining material------------..._...................... ❑ Size: Diameter------------------------ .... Depth....................................................Liquid Capacity-----------------------------gals. Privy: ..Distance from nearestr _________________________________________Distance from nearest building___. ............................... ❑ Distance to nearest lot lineA-----_------:-------..-_-------------- --_--••----•----------------------------.--------------------------- .............---_.---- `. Remodeling and/or repairing (describe):....... ..'""- --------------------- ------------------------------------------------------------ -------------------------------- •------------------- --------------------------------------- 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 oa quin Local Health District. (Stgned)------------ - ---- -------- - ------ -••-•••••---•---------------;Owner and/or Contractor) - - -- ---------• - = — :{Tt e) -_-__ ,_... : .. ----------- x — _ -: .: -- (Plot plan, showing size of lot, location of.-system in relation to wails, buildings,,etc., can be placed on reverse sid_e). y FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.-- -`---- -----------------------•--•=•••----------------- DATE.,_,/--------------- •----•-=-= REVIEWEDBY---------i-------------------------------------:---•-••-------------------------•------- ------ DATE-------------------------------------------------------------- BUILDING ---- - - I BUILDINGPERMIT ISSUED------------------I•-----•-•-------------------------------------"-----•--- -------------------••. DATE------ -------------------------------------------......... Alterations -----------...--- Alterations and/or recommendations------------------------------------------------ ----------------------"-•----------•----------•------------------------------•------• -------------------- +, :--- --------------•--•-------------------------_---------------------------------------------------_---------------------------•--"----------------- ------- -• -------------------- .......... r ............. ......... ............. ------...............------..... ...__......_.....------------ ------------------------------------------•- - -. ........._... �y. FINAL INSPECTION BY:.- rs!%1:.. • `� h,�Date,"w r U---- --3_-_.-___"_.---- ----------------- y � SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 309 West Oak Street 124 Sycamore Sireet 205 West 9th Sireet Stockton,California Lodi,California Manteca,California Tracy,California Fs 4 REv16ED 93-59 :Am 3-163 F.P.Co. � f