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FOR QFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. .l --------------------------------------------------------- - ... -Z_ . ------------------------- ------------------------------- (Complete in Duplicate) �s-U ------------------- This Permit Expires 1 Year From Date Issued Date Issued ....................... yi 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-..._;L..... �I O -Lf.i.� f -�► .f.. _ - '--------.............. s Owner's Name-------------------------- - -!_e'A40V5------ ---------------------------------------------------------•- Phone....5,'�.�.�_R_�_7a.� Address--------------------------------....... ---------------------- -----------------------------•---------------------_=.....' Contractor's Name------------------_'a-----13P_---Sje_-Ir ----------•--------------------------•-------------------- Phone........•-------------- ......--- Installation will serve: Residence 04 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___I-_ Number of bedrooms _=/--- Number of baths ._' Lot size ....... --_____________ Water Supply: Public system ❑ Community system ❑ Privatejtg. Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: :Sand ❑ Gravel ❑ Sandy Loam [❑ Clay Loam ❑ Clay ❑ Adobe,;4 Hardpan ❑ Previous Application Made: {If yes,date____. _--__) No e New Construction: Yes ❑ No ❑ FHA/VA: Yes$4 No[] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) i Septic Tank: Distance from nearest well__A3D-�Distance from foundation-------- ,_......Mate rlal____�G?�11C No. of compartments------------A...-------Size---- Liquid depth-------.----V_f.--------Capacity______- Disposal Field: Distance from nearest well_/r _/_.D-stance-from foundation____-V?.0-_ __.Distance to nearest lot line------;?_2... f ------.Width of trench--------_�---------------- Number of lines_.:_________.__-_______ _______ Length of each line------------ Q___ r(� Type of filter material_ C --___Depth of filter material_______-1V________.__Total length------------- «___________.__.___. v Seepage Pit: Distance to nearest well--/6' _eo___Distance orn foundation-----:s.'Q__--..Distance to nearest lot line___ -_�_ .� Number of pits._.. __/---------Lining material----- ---..Size: Diameter___- ...___Depth----_c. _�-------------- O r Cesspool: Distance from nearest well_________________Distance from foundation---_----------------Lining material______.________--_--_________________ Q ❑ Size: Diameter--------------------------------------Depth-----------------------------------------------------Liquid Capacity------------------------_-- v t Privy: Distance from nearest well------_------------------------------------------Distance from nearest building----------------------.----------.-------- it lot line--------- ❑ Distance to nea,rie -------------------•------------------ --- Y ` Remodeling and/or rer airing (describe): ------------- ----- -•------------------------------------------- -------------------- -- ----•---•----------------••----..._. ------------------------- �Q---- 4e;,WV7_4114Vy-----.74V I ' l --------------------••----------•-••-------------- -------------------------------------- ------------•------------------------------•-------------------------•--------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, nd ules and're lations of the San Joaquin Local Health District. . 1 Si ned)_--X---- - ----- --^'a--- (Owner and/or Contractor) By Title (Plot plan, showing size of lot,_loceflOn of system in relation fo wells, buildings, etc., can be placed on reverse side). I b: 1 f :FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- ------------------------------- DATE---,X-- 5- ---C--Q-------------------------- REVIEWED ------------ ---------REVIEWED BY------------------------------------=------------- - ----------•-----------------------------------•-----------._..._.._... DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------•-ji-------------------------------------------------------------------------------------- DATE------------------------------------------------------------- ' Alterations and/or recommendationsI------------------------- ' r --------------- - -- -- - ------------------- 14_0 -------- -----•---------------------•-- ---------------•------ ------------- -------------------------------------------•------------------- ----•-------------------------------•-------.------•---••----•-•----•------- ----------------- ------ ------------------------------------------------ - --------------------------------- ------•---------------------------------•- --------•-- - -------------------------------------••--------------- FINAL INSPECTION BY: i> Date_t - ` SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ... ES•9 REV16Ed 8.59 r.P.CC.1M 6.60 +� y,