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FOR OFFICE USE: ---------------------- --------------------- ------------ APPLICATION FOR SANITATION PERMIT Permit No. .. - �- (Complete in Duplicate) rfp #This 'Permit'Ex ices 1 Year From Date Issued' 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-----3- - - Jr� ...... � _bA -----------------------------•--------------- --------------------------------------- - Owner's -'-�� ' ; Phone..:tlL,3--=---QRli........ i , �� } Address-----•--------------------- -------------------� -------------=----------------------------•-•-----•-•----------------------------- I ---- ----- ------ Phone................_-" Contractors Name------•---••--------s�--��-Y-�"�-.------•------ -----------•----- -------=--•--------------•---•--------••--• -• ---•---------- 0. Installation will serve: Residence W Apartment House"❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ . Number of living units: :- _ Number of bedrooms __a;Z- Number of baths ...ram. Lot size ----- Water Supply: Public,system f5Z Community system ❑ Private ❑ Deptth Jo Water Tab .C�1-ff. Character of soil to a depth of 3 feet: Sand ❑ ` Gravel ❑ Sandy Loam ❑�C a�.y Liam,❑ Clays❑ AdobeE Hardpan ❑ Previous_Ap^plicafiionMade;y[Ify,esd.ate_______ ,-_<___�_No-G-•--New-Construction-:Yes-❑—No[] F1�A��TA:Yes'❑""No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 1 (No septic tank or,cesspool permittedif public sewer is available within-200 feet.) Sqatir Tank: Distance from neirest well_If &. ___Distance from foundation__:_-__--------___Material-__.__-Cr'K:__._ _._:_ _-___------_-._--... No. of compsrtmenfs_ �--'------- --Size--------- ------------{-----=--:Liquid depth--------------------------Capacity--=-------------------- v Dispos_a Field: Distance 4om�nearest well._'__4_------------Distance from foundation___________________.Distance to nearest lot line------------------ ❑ Numbe f fine+ . f r- Length of.each line = Width of trench Type of filter material--._---- �Li-------.---Depth of)filter material--------------------Notal length----•-.-.--•-----:-------------- Seepage Pit: Distance to nearest we71`' _______ _Distance from foundation -_)__� .. _.Distance to nearest lot line_ r Number of its-----------I _ Linin material____ 1.Size: Dia.mdter_ '_"_.�/.Depth_ -------.-_- Cesspool: Distance from nearest`well______-----------Distance from f�nda- ion---------- ±_. ini�g material.-_-_________----------------------- . :. ❑ Size. Diameter--- I ----Depth------------------------------------------ ----------Liquid Capacity-.---------------------- Privy, ------=---- ------Privy: Distance from nearest well -----------___-------------- _ _ Distance from nearest building---------------------------^_-.---___ � '`Distance to nearest lot line. -------rr-:---- - ------- ------------------------- ' Remodeling and/or repairing...(clescr;be)=-------';-------- --------- • -------- -------- i i •---•--------•- " ( s-------------- :: s I ! t ---------------------- ------------- ------------------•-----•-------------I--------I ------------- -----•-- � �-----------_ ---------------------------•--- ---•----------------- y 1 hereby certify that I have prepared this application and that fhe work will,be done_in"accordance with San Joaquin Count i$ ordinances, State laws, and rules and regulations of the San Joaquin Local Health District . I wj--r �--'--- - _.- . _: �0 Owner and/or Contractor) (Signed) E ` _ J ti. - f �_ --Tytt (Plot plan, showing size of lot, locationof system int relation to wells, buildings, etc., can be plgced on reveirse side). ' R DEPARTMENT USE ONLY 1 F . 1 APPLICATION ACCEPTED BY--' t - REVIEWED �d BY-,------------------------------------------------ -=----- ------------------'--------- ------------------------- DATE------------------ ---------------------------------- BUILDING PERMIT ISSUED---------------- i - - -------==4----------::----------•-- ;--------L-.----------------------- DATE------ ------- -- - - - - -------------------------------------------- Alterations and/or-recommendations::_._— ---�--::---- __.: ---:------ - - " -•---------------•-------•-------------------•-•---------------------•- -------------------------------------•---------------•---•----------------------- --------------------------------------------------------------....-,._.-_------------...__------------------------------------- ------------ ----------------------------------------( --.- ---------=--------- --------------- -- ---•--- ------ I FINAL INSPECTION $ -- ------------ -- ------ --- - ---------------------------- -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California EB-9'REYMED 6.59 r.P.CO.JM$-6❑