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FOR OFFICE USE: ---------------------------- APPLICATION FOR SANITATION PERMIT Permit No. - Zd", i ------------ ----------------- ------------------------- (Complete in Duplicate) Date issued -6 -------------- This Permit Expires l Year From Date Issue Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described.. This ap lication is made in compliance with County Ordinance No. 549. JOB-ADDRESS AND LOCATION.-ZY11 - ''`':r�"s�' _- - ------------------------- Owner's Name----- • - ----------------- ---------------------- Phone------------------------------------- Address------- ... -- •---� r/--- ---- --- ` :. if Contractors Name--- - ------------- >•-----------------------------------•----- ------- --•--- Phone----------------_--------------- Installation •Installation will serve: 'Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel '❑ Other ❑ ----------------- Number of living units: --�--_ Number of bedrooms qZ/ Number of baths - • Lot size --------------_--.----- -- - Water Supply: Public system ❑ Community system ❑ Private Depth t Water Table .--- ft. ' Character of soil to a depth of 3 feet: Sand E] Gravel [I Sandy Loam [Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date----------------_.-) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ 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-----------------Distance from foundation--------------------Material---------_----.---------.-__-_---_....-.------. ❑ No. of compartments---------- --------- -----Size-------•----------------•-------Liquid depth--------------------------Capacity---------- ---`------- `�// i Dispos i Field: ,Distance from nearest well----'7"'�--__Distance from foundation. I_-0-------.Distance #o nearest lot �ne_ __.---__--- Number of lines------- _ Length of each line__457-.--------f-__-..--Width of trench--_-J----.,--------------------- Type of filter materia-_ -- --------______-Depth of filter material----.-.f-- -------__..Total length_-__-.�----------------------------- f f , Distance to nearest well-..-. S ------_---Distance nearest lot n_5-------_p___-- Q Number of pits-------- ------------Lining material------*5-R-------Size: Di.aq4e+era- -- ---Deptn--------- --------- Cesspool: -Distance from nearest well-----------------Distance from foundation------------------..Lining material--..--_---.-..------------171 _---_-- Size: Diameter------- ------------------- - ------Depth_---------------------------------------------------Liquid Capacity----------------------------gals. Oc Y. Privy: Distance.from-nearest well----=-----=------------------=---------- Distance from.nearest building------------------------•----------------- ❑ Distance to nearest lot line-------- ------------ -------------- ------------------------- ---------------------------��1 Remodeling and/or repairinq' (descr-sbe):----------_ __ ---------- vl ----'� ID- ------------------------------- 41 -----------------------------------I--------------------- ----------------- ---------- I hereby certify that I have prepared this application and that the work will be done.in accordance with San Joaquin County ordinances, St laws, and rules and regulations of the San Joaquin Local Health District. (Signed) --- - ------ -------------- ---------- ----- ------------------------------- -r-and/or Contractor) gY- -------- -- -- -----------------`------ -------------- ----- ----------------------------------------------------•(Title)-------------- _:------------- ... ......--.-.-.._-- (Plot plan, owing size of Ipt,.location o stem in re tion to wells, buildings, etc., can be placed on reverse side). e --... FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED. BY------ - -------------- DATE---- l �f ---------------------------- REVIEWEDBY----- ------------------------------- ----------------------------------• DATE-----------------------------=-----•---------------------- BUILDINGPERMIT ISSUED----------------------------- ---------------------- DATE----------------- ----------------- --------- --------------- Alterations and/or recommendations:--------------------- ---•------------------------ ---•-----••--------•-------•------------------------------- FINAL INSPECTION BY----144- ------- --------•---- - - ----- Date_...f �? �� --------- ------------------------------------ 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 ES % REVISED 9-99 3M 3•'63 F.F.Cd.