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FOR OFFICE USE APPLICATION FOR SANITATION PERMIT Permit No. ------ (Complete in Duplicate) 17 ----------------- -------- -------- - Date Issued �r--�- ---�----- ------------------ ------------------------- This Permit Expires I Year From Date Issued 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 A .OCATION______.__�_/_�------_-�_:- -- e-rte & �-------------------------------------------------------------------- Owner's Name,/-'---- . "------------- ---------------------- ---------------- -- ------------- Phone----------------------------------- Address------------------ P",--- ---------rf zi / 'e Contractor's Name----------1- -------- -p!k---------------------------------- --------------•------------------------------- Phone-----------------------=----------- Installation will serve: Residence [D-Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --.- .- Number of bedrooms --.-1--- Number of baths ----j- Lot size ---------------------_---- Water Supply: Public system ®/Community system ❑ Private ❑ Depth to Water Table _4�- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe g.,-Hbrdpan ❑ Previous Application Made: (If yes,date-- ---`-------------) No 9-' New Construction: Yes ❑ No E§--"SHA/VA: Yes ❑ No Lar,., TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet. Septic Tank: Distance from nearest well-----------------Distance from foundation------------------.Material------.----.---------------------------.----.---. / 1%/f✓�No. of compartments------------ - ----------Size-------- ---------------------Liquid depth--------------- -- ---Capacity---------- -----------� Disposal Field: Distance from nearest well------ -----Distance from foundation---lv-.!-----.Distance to nearest lot line---�--.----- Len th of each line---- �--__ - [ � Number of lines---_-_ -----t--- _. g ____..Width of trench.---f -------------- � ,fPY �e of filter material-_1-1�. ioc -Depth of filter material---.---�{�.�._-__Total length--- _--__------_-_r------___-.- Seepage Pit: Distance to near well-----� Distant rom foundation----/--V-----.Distance to nearest lot line- -------- - ❑ Number of pits_._.---------------Lining material- --C/�--.--size: Diameter-_�3-��.---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 - --- ------------------ ------------------------------------------------------------------------------------------------------------- � � of Remodeling and/or repairing (describe----------- ----- -- -- _ .-�_-__��[! , ----_-.-- -- C --- -----------------------------------------------------------------------------------------------------------------•--•------------- ---------------------------------- -- ----------------------- ------------------------------------ -------------- ---- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State law , d rules and IRgulations of the San Joaquin Local Health District. a h�� (Signed)-------------- /V�------2 -------------------------------(Owner and/or Contractor) / -- B --------------- ,-414 - --------------------- --------------------------(Title)---- --- ------------- (Plot plan, showing size of o , location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY ' APPLICATION ACCEPTED BY----- - ------ - --- DATE.-------- REVIEWEDBY--------------------------------- ------------ ---------------------- ------------------------------------------------------- DATE----------------------------------------------------- - ---- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------ ----------------- DATE-------------------------------------------------------- --- - - ..- ....,. .._._ Ite ations��.f'�ommendationsi-------'---- - ---=�----------- ---------- ------------ -- --�------- ='--"'--------------------------------------------•-------------------------- �-11- .. ....... 7 -G_.....-- -- ------- -------------------------- -- -----------------------------------------------------•-------------------------------------------------------- ----------------------------------------------- •------------------------------------------------- --------- ---------------------------------- ---- -----------..------------------------- ---------------------------------------------------------- -------------------------------- ----------------- FINAL INSPECTION BY:----------- ----------------- - -------------------------------- ate--.-- , SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 1 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California o Manteca,California Tracy,California