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FOR OFFICE USE: V APPLICATION FOR SANITATION PERMIT Permit No. --- -------------------------- u (Complete in Duplicate) Date Issued This Permit Expires 1 Year From Date Issued 1211 -1 Application a#ion is hereby made to te San Joaquin Local Health District for a permit to construct and install the work herein described. j This application is made in comphlianee ith Cou ty Ordinance Ng 549. 1— b� trl Y F ti JOB ADDRESS AND LOCATION ) J �J --------- -----------V------ --------- --A-4-onl-------- Owner's Name -------------- -------- --- - .-- Phone------------------------------------ �-�-0-------- ----------------------------------•--•------------------------------------ Address-------------------------------- Contractor's Name--- ------------------------ -- ---- ---------------------------------------------------- - ----- Phone------------------------------------ Installation will server Re�dence, —Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of"living units: -------- Number'of bedrooms —5 - Number of baths _ ___ Lot size -------o2--- ______________________ ` Water Supply: Public system ❑ ; munity system ❑ Private 2---Depth to Water Tablet ft. Character of soil to a:depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam lay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ f :Previous Application Made: (If.yes,date -------____--------) No []/New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ ! I` -TYPE OF INSTALLATION AND SPECIFICATIONS: t, (_oTseptic.,tank_or,cesspool,permitte.d if--public sewer is_available within-200 feet.).,_ 4� _ Septic ank: Distance from nearest well-- _ __DlstancpfP/m fp,xl a�on- ----------Materi ✓LeG o �! [ No: of compartments-:_ - Size- - _--�2- e_Liquid depth -5�f-------------Capacity__ - --_-- R � � / Disposal ield: Distance from nearest well-Pe �_.__.-_Distance from foundation__//__ ___ Distance to nearest lot Is a __,___--__- kj .w !n Number of lines_ .. --- --- : Length of.sach line---------- 0Q-----------Width of trench- ---- �,- I Type of filter material.___� epth of filter material 1�__- -.__-_Total length___.__�r ____�Q ___._ G Seepage Pit: Distance to nearest well /Q*0:011. ___Distance from foundation ________ Dista'}ce to nearest lot line------��' Number Of ts_ .- -- -- - Lining material__- Size: Diameter_ ___& ---------Depth----- --------- - Linin material------------------------------------ . Cesspool: Distance f.:i,om n earest"wall .Distance:from foundation= _._ g l [] )Size: Diameter--_t .`------------------------------ ---- --Depth - --- - -- -- -- --- -----------Liquid Capacity- -------gals. Privy: Distance;from nearest well__-- _ ___ _ :________ ___ ____ ___ D"istance1from nearest building______ --_ ---------------------- ❑ ''Distance to nearest clot line---------------- '---------------- --------------------- -------------------------------------------------- ------------------- ! e'' -Remodeling and/or repairing (describe):------------------------------------------------ ----- -�------------ � a� '�is i rt - ----- - -------------------------- ------- ------ ' --------------------- -------------------- ---------------- - ----------------- ---------------------------------------------•------------------------------- # ---- --------------------- ---- ----- ------------------------- --- --- I hereby car if that I have prepared this application and that the-work will be done in accordance with San Joaquin County 10 ordinances, Stat laws, and rules and regulations of,fine San Joaquin Local Health District. [Signed)-------- --- - ----- ---- --�'- -- ----------- ------------------- --=------------------------------------------------ ------------------------(Owner and/or Contractor4_11� By: -- ----- ----- ----- -------- -(Title)-------------------------------- ------- if".(Plot plan, showing size of lot,:location of'sys em in relation to wes,Tbuildings, etc an b placed on reve�se�side) t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-Al rl--C R� ------------------------------------------------------------ DATE------ ---REREVIEWED VIEWED BY---------A-------------------------i------------------------------------------------------------- --------------------------- DATE----------------- ------ --------- BUILDING PERMIT ISSUED--------------- --------- ---------------------- DATE._-------------------- �. Alterations a14d/or recommendations! ---------------- --------- -- ----=------------- ----------------------------------------- ----- ----- -� L- 7 66-_--- y� o C002>!* _ f AQ>----cl-f RAV€c-- -Tr I a:_--------- A -------------- ------- ----------------- ----------- (K�A� "Date FINAL INSPE ION BY:-. - . - _.-. .� - .. --------- t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 4th Street Stockton,California Lodi,California Manteca,California Tracy,California .ork F.P.Ca.