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F R OFFICE USE: ------------------� - ------ ---------------- - -- -------------------------- -------- APPLICATION FOR SANITATION PERMIT Permit --------------------- --- --- ----------------------- (Complete in Duplicate) This Permit Ex ires 1 Year From Date Issued bate Issued -----_1------- Application is-lferpby made\to the Sao Joaquin1t)cal Health DistrictJq)r a permit to construct and install the work herein described. This ap'licafion``is+�ade in compliance with County Ordinance No. !A,9. f • 'fi ,.�j �/�%�9,�i�IC.tai JOB ADDRESS AND LOCATION_ `---.; -?- Owne`rr's'NName--------- i /' i Z/ 5 ..,E :-:, Phone_ :- -7 . Address------------------ +1�.� �� --------------•- Contractor's Name------ --- y /j _ n! ----------- -_... -----1 Phone----• -- --------��-�1--' Installation will serve: Residence ge Apartment House ❑ Commercial' E]"'Tlra'�g Court ❑ Motel ❑ Other ❑ Number of.living units�__� Number bf bedrooms _-_ Number;of baths -_Z__ Lot tize ------- ------------------ Water Supply: Public system ❑ Community system D❑" Fri'vate�® Depth to Water Table!&--- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made:_If yes, -No ® New Construction; Yes (TJ No K FHA/VA: Yes ❑ No TYPE OF INSTALLATION�AND SPECIFICATIONS: , (Nb septic tank or.cesspool permitted if public sewer is•available�.ifhin 200�feet.) �e Septic Tank:. Distance from nearest well_-_____----.----Distance..from_foundation__-.:- .-----.Material--------------------------------------------_.,. ❑ No. of compartments- ------------------------Size--------------------------------Liquid depth----------- --------------Capacity----------------------- = II Disposal Z41 Distance from nearest well.16-0--_ _ ---Distance from foundation-!9 __�yDistance to nearest lot 71/ Number of lines....i-,�'�------- --------------Length of each line-----f- -----Width of trench---.- 7_ f� -------------- ------- Type of filter mate iia-t ?`/L� t --Depth of filter material----1-9_"__--..Total length--------%rte--.F/-------------- i Seepage Pit: Distance to nearest well__-_----___.____._-.-Distance from foundation-------------------Distance to nearest lot line__--_.----.----_ ❑ Number of pits.----'- k-- ------Lining material----------------------Size: Diameter.-.-------------.-.---Depth--.------------------------------- Cesspool: ------.---------.---_ 'Cesspool: Distance from nearest well-----------------Distance from foundation------------------- material------.------------------------------ ❑ Size: Diameter___--- _]_�_ _ +� - - --------�---�-�- Depth--------------------------------------- - --------.Liquid Capacity-----------�------ � --•--gals. 7 , Privy: Distance from nearest Drell__________________ __ -------------Distance from nearest buildingf° ❑ Distance to nearest`lbf:lin/e�----/-------------- --------------------------•---------------------- Remodeling and/or repairing (describe): + - _______. •� _ --- !- --_-----_ �,.�.T'.1/5l '------�h' --/S/ -------------------- --------------------------•-------------------- -----------------------------------------------------------------------`----------------------- -------- ----------------------------------------------- -- --------------------------------------------------------- ----------------------------------------------------------------------•-------------------------------------- --- ----------------------- 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 t}ies_San Joaquin. Locol^alth District, b (Signed)------ %- l _ ------_ --. -w �- -------- ------------------------------------------------------- w r and/or Contractor) ! fi $Y=------------- _ ---------------------------- --------------------------------------------(Title)... --- --------- -- ---- -------- F_� (Plot plan, showing size of lot, loc-�oniof system in relation-to-wells.•-buildings, etc., can be placed on reverse side). y 1 i FOR DEPARTMENT t1S, ONLY {t APPLICATION ACCEPTED BY------ ----------- ------ DATE-------- REVIEWEDBY------------------------------------- ---- ----------------- ------- ------ ------------------------------------------- DATE---------- ---------------------------------------------- BUILDING PERMIT ISSUED------------------------------------------------------ ---------------------------------------------- DATE Alterations and/or recommendations:---------- ---- -- -------- =----=------------------------------------------------------•------- -------------------------------•------------------------------------------------------------------------------------------------------------------------------•---•----------------------- ------------------•---------------- ---------- - ------------------------------------•-1---------------- -----------------•------------------------------------- ..� s\ r.. x ------------- ---------------------------- --------- ----- -- ---------------------------------------- -•------ ------------ ----------------------- ------------- -------- -- ----- FINAL INSPECTION BY:---_ -- __ ------ date------ --- ��-----� - 4 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 llest 9th Street \ Stockton,California Lodi,California Manteca,California Tracy,California F.P.CO.