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FOR OFFICE US >. ~— --------------- APPLICATION FOR-SANITATION PERMIT Permit No. _,�t _:...�_-_ - -- ------ ------ ----------- -------- --------- (Complete•in Duplicafe) ------------ --- This Permit Expires 1 Year From Date issued Date Issued Application is hereby made to the San Joaquin Local Health District for a'permit fo-construct and install the work herein described. This application is made in compliance with ounty Or man e-No. 549. .i. r�� ;; . JOB ADDRESS AND LOCATION------Y'' :i =- ;,-- ----- -•gid------------ P, =----- ___"'_k,� t ......_ I .,, _ --- --------.-{'_ _Phone ',K_)_-' M � Owner's Name-------T p --- ;r.:_.... T '�-! ______________________________.____.._.._______-___.._______.-_...._...__.____._ Address-------------•------------_.::..L'...._ :.....-- .�� 1: . ,------------ Contractor's -i C. Contractor's Name...OWNI `"----•- _-�:_. A :-----1- A.f t�19i °---- •- ------------- --•-------_--- Phone------ ---------------------------- Ins#allation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel E] Other ❑ Number of living units: ___ Number of be_ roo ms "------__ Number of baths_'w Lot size ----- ------------------------------- _ Wafer Supply: Public system ❑ Community s tem E] Private " Depth to Water Table / z_ ft ' Character of soil to a depth of 3 feet Sand (Grave! ❑ Sandy Loam [:1 Ciay Loam F] Clayz❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date._.. No Q' New Construction,: Yes' No ❑ FHA/VA: Yes ❑ No [✓]' TYPE OF INSTALLATION AND SPECIFICATIONS:, _ - (No septic tank oror cesspool permit#ed if public sewer'is avail' able within 200 feet.) : it t r -> Septic;ank: Distance from nearest well__, _ .______Distance from foundation_..__!: _.___._..Material C r!<.7__._`^-- ?- r ;.." j y ria F % ©� No. of compartments----_�+4___--------------Size__�__:t`_-v'-�--�+- ----------Liquid depth--'-'-�-'-'-'- ....... Capac�ty..dc---- --- ,�A_ Dispos I Field: Distance from nearest well. ~`.,---------Distance from foundation.._j_%_._......-.Distance to nearest lot line_-"t'__�.____. �- Pq Number of lines-----------a'.t=.__..............Length of each line__ __(,,_.`t_____„_.._._.Width of trench-----`--____-__._._.________--_ ,�. V} Type of filter materia!_�_�:...t-��zf Depfih.�of filter material___�_______ _____.Totai length------�L� ------------------------- Seepage Pit: Distance to nearest well----------------------Distance'.from foundation___________________ Distance to nearest lot line----- ----------- ❑ Number-of pits--- ----------------Lining material..... ............ Size: Diameter-----------------------Depth------------------------------- Cesspool: Distance rom nearest Well`__ '�”"'"Dis"fence,from�ound-afion:. ._ __ ""`L"ming'mater ial____________________________________ 171 Size: Diameter- -- --------- ----- ----------------De th------------'------- --------------------------Liquid Capacity ---------gals. Privy: Distance from nearest well .................._.-._._....._._________._._.Distance from nearest building,____._-.__- ._____-__..________- ❑ ...,r'l w . ., r * -- -- - ----- Distance to nearest lot Ime:_ s' '- - -------------------------------------------- - Remodeling and/or repairing {describe) ------------------------------------•-•--------•- •------------------------ ---- ------------- ----------- ---------------- •--------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have,,prepared #his-application.and_fhat7the work will-be.done_in_accordance with San Joaquin County ordinances, Sta#�ws, and rules and regulations of he San Joaquin Local Health District. i --- - _Z_________________{Si ned)- '-- ' (Owner and/or Contractor) t_ .. --------------- ---- '.......... ' ------------------ ----------------- (Plot - -------(Plot plan, showing size of lot, location of system in relation to ells,buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION,ACCEPTED._B�Y__.- -R_. ..:= .:. - F -= ------------ ------------- DATE_-------- ' IV- REVIEWED BY ------:---- - -- -' --' - ----------------- DATE------`---------------------------------------------------- BUILDINGPERMIT ISSUED-------- ----------- --------- ----------------- ----------------------------------- --------------- DATE------------------------------ ` Alterations and/or reco mendafions------------------ -------- - --------------------------------- -------------- - ' ' ------------- -- ------------------------ -- ------------' ' =--------------- ---------------I------ -----------------------•-- ------------- ---------------------------- ------- ' ' - ' ----------- ----------- - ------------------------ ----------------- ------ ..../~? ------ ------ --- - -------------------- ...... -------------------------------------------------------- --------- --- ------------- ---- --- ------------- ' ' --------- .......-------------------------- FINAL INSPECTIO ---.-- -- Date--'-'-----' 1 � ---------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Nazelton Ave. 300 West Oak Street 724 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California E.H.92M 1-67 Vanguard Press - i