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FOR OFFICE U5E: -------------- Q-f APPLICATION FOR SANITATION PERMIT Permit No. '2�xf ---------------------- ------------ --------- ----------------------------------------—-------------- -------------------------------------- ------------------------- (Complete in Duplicate) Date issued - ------------------------------------------------- - - This Permit Expires 1 Year From 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--K-------+rll -- -- ------- ---7r --------------•------------------- ---------------- Owner's Name •�f' � -------ll - --------•----------------------------- --------------------------- --- ------ Phone------------------------------------ ---- Address---------W ------------- ----f------ ----- - - ------------------------------------------------------ - - - - - -- Contractor's Name--- ------------------------------------------------------------------- ------- --- -----•- --------------- ------------ Phone------------------ --------------- "Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel 0 Other ❑ Number of living units: __/____ Number of bedrooms ._f--- Number of baths 1----- Lot size ________________ Water Supply: Public system ❑ Community system ❑ Private U�-�epth to Water Table _.4_6ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [1—Hardpan ❑ Previous Application Made: (If yes,date_------------------) No [ New Construction: Yes W--No ❑ FHA/VA: Yes ❑ No []-- TYPE OF INSTALLATION AND SPECIFICATIONS: ; (No septic tank or cesspool permitted if public sewer is available within 200 feet.) It Septic Tank: Distance from nearest well- --- ---Distance from foundationl4--------------Material_..______._.___----------------------- ------------------- No. of compartments------ ---------- ---Size-------- ---Liquid depth----------f-.---------Capacity-- Disposal Field: Distance from nearest welt-%"--�------Distance from foundation--- f?`- ____._.Distance to nearest lot line_________.__--___ 09-- Number of lines----/--------------.---------.----Length of each line---k---o--_'---------------Width of trench _g_.4_.._.________.___. Type of filter material-- --17,aCA__-___Depth of filter material--- $--------------Total length----------rQ_---____-________._- Seepage Pit: Distance to nearest well-----------------_----Distance from foundation--------------------Distance to nearest lot line_--_._______.._ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth---------------------_----------- Cesspool: Distance from nearest well-----------------Distance from foundation___-----_-----------Lining material ...____..______._____.____._____.___. ❑ Size: Diameter------------------ ------ - ----- ----Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well---------------------------------_---------------Distance from nearest building----------------------------------------- f-1 Distance to nearest lot line-------- --------- --------- ---------------------------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe)----------- ----------------------------------------------------------------------------------------------------------------------•------------------------ -----------------•--------------------.--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------- ----------------------------------------------------------------------------------------------------------------------------------------•-------------------------- ------------------------------------------------- ------------------------------------ --------------------------------------------------------------------------------------------•--------•---------------------------------------------------------------------------------- I hereby certify that ave prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, ru nd regu tion of the San Joaquin Local Health District. (Signed).--------- --•-- --- t ------ ----- ------ -------------- ----------- -------------------------------------- By: ------------------------------------ (Owner and/or Contractor) I B ----------------------------------------- ------- 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----------- ---C1------- - ------ ----------------------------------------------- DATE-----------c fc '.----------------------- REVIEWEDBY- ------------------------------------------- ----------- ----------- ------------------------------------------ DATE--------------- -------------- ----------------------------- BUILDINGPERMIT ISSUED--------------------------------------------------------------- ------ DATE-------- -------------------------- ------------------------- Alterationsand/or recommendations:----- . -- - - ------ -- --------- ---------------------------------•------------------------------------------------------------------------------------ --------------------------------------- ---------------------- - - -------- ------------------ ------ --------------- ------ + �^.� crfiC eJ v 1 of ylro t !� r -------- -- p &e'triL �l ti ---------- ---------- FINAL INSPECTION BY---------------- - --- - Date....... --1V- kfV11"&---- ------------------------ 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 F.p.co.