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FOR OFFICE USE: _ -------------------- ------------------------------- ------------- APPLICATION FOR SANITATION PERMIT Permit No, I�Z-I.Za7 3 i - --- -------------------------- --- ! (Complefe•in Duplicate) --.-.--- i This Permit Expires 1 Year From Date Issued Date issued Application is hereby made to the San Joaquin Local Health District for a permit to constrct and install the work herein described. This app iirc-7ation.is/made in compliance with County Ordinance No. 549. �(e3 —99 70_ 7 j JOB ADDRESS AND LOCATION_! - -.. 7 "_, -- - -G n A ± Owner's Name-----16 - --------------------------------------- ------------------------------------ ---------- Phone------------------------------------ Address - -?-P---0-------------- - ---- Contractor's Name.. ---------- ----------------------------------- ----- ------- -- -------------------------------------------- Phone...... •----•-----------•--------- Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -:�.---- Number of bedrooms _3---- Number of baths`_r��_Xot size --__ _- --..-_-. __ -- •--•-- ------------•----------- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table S- ft Character of soil to a depth of 3 feet- Sand ❑ Gravel ❑ Sandy Loam Dp Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: {If yes,date-----------_.._- - I No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ,y tank or cesspool permi4ed if FubPc sewer is available within 200 feet) Septic Tank: Distance from nearest well_r _,+Distan . /from{foundation__./O---_--__.Material - �' No. of compartments- "' -------_-_ Size-=------- --=-�.>'"-r----Liquid depfh.--------411-- -------_Capacity- -- -4- ----- r Disposal Field: Distance from neare t well.t-®_4_._._Distance from foundati n--/R--'t---.-.Distance to nearest lot line-4 - -____-- IT] Number of lines.--- ----- -------------------_Length of each line--.-- ----y----------.Width of trench A-Y-.r-___-_-._____--_-------- �1 Type of filter mafieria !_9--_.__.-_---Depth of filter material___aA_Q'--------------Total length___.63_____.______------ Seepage Pit: Distance to nearest well--- -------------Distance from foundation--------------------Distance to nearest lot line----------------- P. ❑ Number of pits.. ------------------Lining material---------------------- Size: Diameter-----------------------Depth---.-------------------_--------- n Cesspool: Distance from nearest well ----------------Distance from foundation----------------- _ Lining material__--------------------_--------------- - ❑ Size: Diameter- -- -------- ---- - ----------- -Depth------------ -- ------------ --- --- - ------Liquid Capacity--------------------------gals. I Privy: Distance from nearest well-___--....... .._._.__.____.....:..............Distance from nearest building----------._-_______.-_ ❑ Distance to nearest lot line _... S - --------------------------------------------- t Remode#ing and/or repairing (descrr�ibe):---- ---------------------------- ----------------------------------------------------------- ------- ----------•------------------ ----------------- ------------------••------------- ------------------- • -------------------- ----------------------------------------------------•-------------------------------------------- ------------------------------------------- r ---------- --------- --------------------------- i----•A-- ------------------------- ---------------------------}--------.----- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State and rules a d re ions of th an Joaquin Local Health District, (Signed)--- ---- ---------------- - ----------------------- ----•----------------------- ------------(Owner and/or Contractor) -------------------- - ---------------------------- - [Title"�_ - ------------- "" --- . (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- - - - -------------------------------- ----------- DATE---- m -------------------- ' REVIEWED BY-------------------------- '------------•------- ----------------------------------------------------------- ----- DATE --------------- BUILDING PERMIT ISSUED---------- ----- -------------------------------- DATE--------------------- - Alterations and/or recommendations: - - ---------------------------------- ---------------------------- -----------------------------------*----------------------------------------------------------------------- ------ ----------- ------------------------ --------------------------------------------------- -------- -- -------------------------- ------------- ----------------- ------------------ ----- -------- ------------ -----------------------------------------------^---- ---------------------------------------------------------- - ------------------------- ------------ --- - -- -------- --------- -- --------------- ------------- ------------------------------ ----------•--------- -•-••----------- W FINAL INSPECTION BY: ----------- ---------- Date-- - ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Streeter __ N 124 Sycamore Street 205 West 4th Street Stockton,California Lodi, California Manteca,California Tracy,California E.K.9 2M 1.67 Vanguard Press c