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F R OFFICE USE: ------ ------- a APPLICATION FOR SANITATION PERMIT Permit No. . .............. ---- /-L2�9C--------------3- - t-_.---------- (Complete in Duplicate) .J 3 �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 construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION---------------- �dn�•0 ------------------ ------ U o/� i1/ Owner's Name------------------- --40,9��41------------- � �-' � r ------ ---------- Phone---'f - - �- Address __...... G7L _, ,0_1_7j� ......................... Contractor's Name-----------------•-- �4 �V- -------- Phone._ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/---- Number of bedrooms __v_ Number of baths --- __ Lot size ------ ------------------- Water Supply: Public system E] Community system E-1PrivateDepth to Water Table 49 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 2--C1ay ❑ Adobe Ej Hardpan ❑ Previous Application Made: (If yes,date--------------------) No B� New Construction: Yes ❑ No [�- FMA/VA: Yes ❑ No [�j- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer wer is available within 200 feet.) Septic Tank: Distance from nearest well___ _..._Distances from oundation____._.___________.Material----- -- ---------------------------- ER" - _ to -, -!---Liquid depth----.,. �/ P y ------ ------`--- No. of compartments-------- _X_ .....__Ca acit �� Disposal Field: Distance from nearest well-----------------Distance from foundation---.______-_-.-__-_Distance to nearest lot line___.___-_____-_-_ ❑ 6�X/.5Y umber of lines-----------------------------------Length of each line-------------------_----------Width of trench------------------------------------ Type of finer material----------------------__Depth of filter material----------------__-_--_Total length.--.____-----.---__-__-____ Seepag Pit: Distance to nearest well____r�Q_______Distance fro foundation---_•�r_`d---------Distance to nearest lot line_. ----------- DF, --___ _ [� Number of pits_--__--/--_---...__Lining material.-rI�,�Size: Diameter._P9.'y._......Deptn__ __ ____________F-, D Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material-----------------.------------------- 04 ❑ Size: Diameter---------------- ----------Depth-------------------------- ------------Liquid Capacity----------------------------gals, Privy:, Distance from nearest well--------------_-------------------------.--------Distance from nearest building----------------------------------------.-. ❑ Distance to nearest lot line----------------- ----------------------------------------------------- ------------------------------- -------------------------------------- fl Remodeling an or repairing (des ibe):---- _ _ -------- -_' -_ -_.---_-- ---------------- ------------------------------------------------------- --------------------- -- - ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 3 I hereby certify thata prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws nd r sand regulatio S of the oaquin Local Health District. Si ned wne nd/or Contractor) 9 )-----------•----- ------ - - -- -----;.Ir---- By: --- -.(Title)----- - ---------- - - (Plot plan, showing size ot, location of syst in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- ------ ----- ------------------------- ------------- ------------------- DATE--- ------------------- REVIEWEDBY-------------------------- --------------------------------------- --------- ------------------------------------------------ DATE-------- ---------------------------------------------- BUILDING PERMIT ISSUED------------- -----------1 -------------------------------- -------------------------------------- DATE.-------------------------------------- Alterations and/or recommendations:______.._ qw- ,.Z=------ -----r ----< ---------------------------- ----------------------------------------------------------------- ------------------------------------fig-/------------------------------------------------------------------------- ---- ------------------------------------------ ------ --------- ---- ------------------------------------------- -- ----------- -----------------------------------------------------•----------- ---------------- ----------------------- ------------------- --------- -------------------------------- ---------------------------------------- --- ------------------------------------------------------------ --------- ----- k FINAL INSPECTION BY:..___ A��Z..... _ �.-r��. Date_.��.—�.-`��--^.------`�r^ - - --------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton, California Lodi,California Manteca,California Tracy,California