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FOR OFFICE USE; I , APPLICATION FOR SANITATION PERMIT Permit No. ...-- _ __7/___. ----------------------------------- -------------------------- ------------------------------ (Complete in Duplicate) ________________________ 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. W,f� JOB ADDRESS ANBD+ LOCATION.- Q -� ------- -----y--� ,••�� -" _ ' Owner's Name-------Y '- E -------------- -- ------------------------_-----------------vim a_t Jw[ ----•--- Phone-- -- hone- Address-------------------2_,p.a_j----- - ------- --------------------13 ' Contractor's Name---------.-_- -1'4-111 ----------------•-•------------------------------------------------------- -. --- Phone----------------........------- - Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __,l___ Number of bedrooms 3-_-- Number of baths -A-. Lot size .... -___________________________ Water Supply: Public system ❑ Community system ❑ Private Jai Depth to Water Table A4� ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay-E] Adobe® Hardpan ❑ Previous Application Made: (If yes,date-.------------------) No IM New Construction: Yes JN No ❑ FHA/VA: Yes ❑ NOA TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) .� Septic Tank: Distance from nearest well_,`z_(G_--t---Distance from foundation___AO----------.Mated I_� f�( No. of compartments------- .__-----------Size__-X____.�-�___........Liquid depth---___'1� p ._v'F..Capacity___fc Disposal Field: Distance from nearest well-_,5a---..._Distance from foundation---1.p----------Distance to nearest lot li�i___�__��__a- Number of lines___.________ _ Length of each Iine407,A&:4X�37.Width of trench._�4_y___________-____ rr��y� Type of filter material r_��_!!�� _______i ep F of filter material_:-�_�_----------.Total length___=,L4!�....................... Seepage Pit: Distance to nearest well__1'jq------------ Distance from foundation__1(1._._------ .Distance to nearest Iodine-----____-___ Number of its----.. Linin material rj _ _ +ze: D%nivter._� Depth P _ g Cesspool: Distance from nearest well_________________Distance from foundation-------- materia---------------------------f--------- r- ❑ Size: Diameter - �-- --Depth----•-----------•---- -----------------<,_------Liquid Capacity-------,- ..`J_� ------- —V Privy: Distance from nearest well------_------------------------------------------Distance from nearest building------------------------------::____-____. ❑ Distance to nearest lot line.-------------------------- a _> --=--------------- -------•---•-- '------------------------- -------•-- Remodeling and/or repairing {describe): - =r-=-=---------"----------------------------------------- •-•--•----- ------------------------------••------------------,,.------•--------------------------------------------•-------------------------------•--------------•---------------•-----------`•-------------------------- -------------------------------------------------------------•-----------•------------=-------------------------._....---- - --------------- � t -------------------------------------------•-------- ----------------•-------"---•---------------------------------------•---------••-- --------------------•----------------------------------- - 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, and rules and regulati,Qns,of the San Joaquin Local Health District. (Signed]_2'• - _.- - (Owne r r� - -- -- --- =w By:---------------------------------------------------------------r------ ''---------------------------------------------------------(Titled:r=; _-"`----------------------------- ------------ (Plot plan, showing size of lot, location of-systern in relaffan to wells, buildings;etc., can be placed on reverse side). �-- FOR DEPARTMENT USE ONLY APPLICATION ACCI PTSD BY--- - ,> - `. - � t�� ,D TE..... --------------------•---- : . 2 . REVIEWED BY_ �-----------=----------------- f - r- ------------- -- ------------------------------------------------ --------- PERMITISSUED---_- -1 ---------------------------------- -------- ---------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations: } ------------------------------------------------------------------------------------------------------- - --------------------- --------•-----•--_ s ' '� .. . � ------------------- y------------- • ----�-----------•---..._....--------------------------------------- ------------------------------------- ----- C, FINAL INSPECTION BY:_ ,--a Date------ -------"!_- �� SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South America n;Street 300 Wed Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California CB-9 REVI9C0 9-99 F.P.CM,aM 6.60