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FOROFFICE USE: -w --------------- ----------------- ' --------- APPLICATION FOR SANITATION PERMIT 'Permit No. --------- ----------------- -------------- ------------- (Complete in Duplicate) This Permit Expires 1 Year From Date Issued Date Issued ---��- �/ r 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 LO ATION_.. ------ "�---Q-�:---- /� C -d/ %ms s C' ;"�P`� Owner's Name------------ t = -------------- -- Phone---------------------------•----- ` Address------------------------ -------------------------------------------•----------------------- Contractor's Name----- ----------- �- Y / r Phone-- - lr .�... ------------------------- -^_ - Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ------ Number of bedrooms -------- Number of baths -------- Lot size Water Supply: Public system ❑ Community system ® Private ❑ Depth to Water Table LSU- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam a Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Mader (df yes,_date__.__,_ --------) No"3Z New Construction: Yes ❑ No �&__ FHA/VA: Yes ❑ No,N TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic yank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------- Material-____________-.------_--------.__-. El No. of compartments----- --------------------Size--------- 1'--------------- --Liquid depth--------------- ----------Capacity-••-- Disposal Field/ Distance from nearest wJlll.-/ae.____Distance from foundation_.,�tP.-`------Distance to nearest lot �]' /,eNumber of lines----------- ------- --------Length of.each line...--_-� -_ -_--_-_.Width of trench--_-_a- ''__------.-•-- Type of filter material__ , Depth of f Iter material-.-,� °____i ---Tot I length � Seepage Pit V Distance to nearest well-.-1L010 __Distance fr. m foundation--: _---------Distan to nearest lot line--2<0_ r_-- lP Number -of pits_:-_---.-___---.__Uning materiaL�le%ee...Size: Diameter. ---- Depth-_, /,,7— CI -------------- ---- Vj Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining materia)_.-..-_---------___-----__-----_-__. ❑ Size: Diameter-----`------ Depth--------------- ------Liquid Capacity----------- gals. Privy: Distance from nea est,well--=---------- -------------------------------Distance from nearest'building-------------------------------------- - y Distance to nearest lot line------___ ________-_-- --------------------------------------- Remodeling and/or repairing (describe):___ ------ ` .----- .S, llrl.� l_ .----- �. -----------Y ------------------- ------------------ ------------------------- ----------------------------------- ---- --- ------------------------------------------ ------------------------------------------------------------------'' ----------------------------------------------------------------------- ------------- I hereby certify that I have prepared this application and that the'work will be done in accordance with San Joaquin County-. --,� ordinances, State nd rules and regulations of the San Joaquin Local*Health District. ` ' I (Signed)---------- 114':J ; - a -------- --------------------------------- (O' r and/or Contractor) F BY: - �-f -o�� .r--------------=-------------------- = (Title) (Plot plan, showing size of lot, locat' n .of system in relation to wells, buildings, etc., can be placed on Feverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED i3YREV ` . - DFTE.:T_!/ __�T` f -- —--------------- IEWED BY ----------------------- ---- ---------I---------- DATE ------- -- ----------------t ----=-------------- BUILDING PERMIT ISSUED ` - 1 1. -------'------------- DATE ------------ Alterations and/or recommendations:-_------:-- ---------------- ---------------------------- __----- ` ---.----m 1•-_------ ----------------------------------------------------------- --------------------------------------------------------- ---------- --------- t t ---------------------------------------- ---------------------- ------------------ ti FINAL INSPECTION BY:.... ._._..._ r,.SAN ��- ----------------------------- Date----------JOAQUIN LOCAL HEALTH DISTRICT1601 E.Haxelton Ave. 0 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy, California F.R.0 O.