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OR OFFICE USE: - :;_ , r r> -- ----- ------- - _______________________________________________ APPLICATION FOR.,SANITATION PERMIT Permit No. .. .__ --- ' --------------- ---------- ----------------------------- a - (Complete in Duplicate) . Date Issued .�-.. -. ---------------------------- ---------------------- - r7;i �.. - This:Permit.Expires 1 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 AND LOCATION_-- _--- -E ��?1,2 110 Owner's Name--- �~ --- = -------------------------------------------------------- -- - Phone--------------- , .�� Address -- lf ��4r !A'-._ . ........ ----- -------------------------------------•- ----------•------•-•- ------ -------- Contractor's Name f one _- '... - -- -- -------------------- -- --------•---- .--_---------• •---•-------- Ph ..-. --------------- Installation will serve: -Residence [��partment Hou ❑- Commercial ❑; Trailer Court ❑ Motel ❑ Other ❑ Number of liv'ng units: _/___ Number of bedrooms ,_--�'___ Number of bath_s - ___ Lot size -------------------------- Water ------------------------Water Supply:; P bluys}em ❑ Community system ❑� Private 9j-,"'Depth to Water Table ft. .4_ Character of soil o a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date---_-.--7-----..----I No ElNew Construction: Yes ElNo [DFHA/VA: Yes E] No [jSTYPE OFANSTALLATION AND SPECIFICATIONS: t✓ -i (No Septic Tian septic tank or cesspool permitted if public sewer is available within 200 feet.) p k: j ! I Distance from nearest well-------------.---Distance from foundation---- -*---°-.---.Material--------_-..---.-_----------:------_-- --------- . No. of compartments ----Size-W. —_1-•-----` ----—Liquid depth---------- - -- --------Capacity----- :" •• Disposal F* I& ` Distance from nearest well:_af�_-_-Distance from foundation.- --_---..-Distance to nearest lot line-- ----.----- i eon Number of lines_-____. :-.--/--__ --_.. Length�of'each line--,� :-* -.�- Width of trench,. ------- -------------------- ¢� 3 Type of filter material-/ i4P Depth of.filter material .-------Total length_-,f ---------------------_-- Seepage Pit: i y Distance_to_nearest wpl� 4 _--- Distance from foundation -------- -----Distance to nearest lot line----------------- �ial+ } Number of pits-----------------------Lining material--` ' --... . e ---Size. Diameter--.--_-------- --------Depth --..-.-------_----- -.--_.---- Cesspool: Distance from nearest well-----------------Distance from foundation___.___-----r.----.Lining material--____.-.----------------------_----- ❑ } Size: Diameter -----. ----.- Depth7_----`--�----------------------------------------- I - Liquid Capacity gals. T 1 --------------- t Privy: _ Distance-from-nearest well________________-....:_.:-----__--.. _.-_---:--_Distance from nearest building_._______-__-_-_--_------- � ❑ Distance to nearest lot line..-------------------------- , -------------•------------------- - ----------------------------------------------- or repairing Idescribe • ---•--------- --------------------------------------------------- Remodeling - an _-- F ! , r---------____________________ i --------------- -------------------------- ------------------------- --------- ........ --------------------------------------------- -----------------------------------.:=----------------------------------------------------------- ------•--------------------------------------`---------------.----------------------------------------------- ----- --.. I hereby certify that h-have prepared this—application and4at the work will be done in accordance with San Joaquin County t ordinances, State laws, and rules`and regulation-�-of th en Joaquin Local Health District.:. (Signed).- 1 = y - 4Z? -- i - �'�or Contractor) BY: - - - (.Title)--t � - (Plot plan, showing size of.lot,_Iocation_of_system in`,�ei - n.to wells„built s, etc, can be placed on reverse side). FOR(DEPARTMENT USE ONLY APPLICATION ACCEPTED BYr�+ -- ---------- ------------- = JKIG_- DATE REVIEWEDBY --- t ---- - ---- _--------------------------------------------------------- •--- DATE------------------------------------------------------------ I ---- ILDING PERMIT ISSUED----------- .°- DATE . ., .Y .� A�iterations and/or re commendations:--- ------------------ °- ---_------- __------------------------ ----.. . -------------------------------------- ---- ` -------------------------- -------------------------- •------------------------- ---= ------------------------------------------------------------ FINAL INSPECTION BY:-.__, .----1�'`” � _.--______________ ' ? � Date----- SAN JOAQUIN,LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oa&Street ,`'��. 124 Sycamore Street 205 West 9th Street Lodi,California Manteca,California •. Stockton,California 7� Tracy,California ES 9 AftWBEo 8.59 3M 3-'63 F.P.CO. �,