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�. ,40R OFFICE USE: ----- ---------IV =3uf..- Permit No. .�' / � --------------------------------------------------------- iAPPLICATION FOR .SANITATION PERMIT (Complete in Duplicate) Date Issued . "j This Permit Expires 1 Year From Date Issued " Application is hereby made to the San Joaquin Local Health District for permit to construct and install the work herein described. This application is made in compliance with County Ordinance No 5 / ----------------------------------- JOB ADDRESS AND LO ATION._ __�,�--------------�-`---- - ------------------- ! a - ------------ Ph;one ... Owner's Name--- - ----� -- --------- - ---- -• -----•----•--•------- ------------- -------------------------------------------------- Address ----- ---------------•------------------_----- Address--------- --•-- _---- - ---- � - Pone ------- Contractor's Name----- �-- 14 -- -------------------------------------------- y 'Motel ❑ Other ❑ Installation will serve: Residenceartmen# House ❑ Commercial ❑ Trailer. Couit [] ` f Number of living units: --/_- Number of bedrooms, 3_ ____ Number of baths _/-_ Lot,size -005_Q - - --4�----------------------------- ; Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table __0 ft. Character of soil to a depth of 3 feet: Sand E] Gravel E3ElAdobe Hard Gravel Sandy Loam Clay Loam Clay ❑ panNo �- Previous Application Made: {lf yes,date___________ _____) No New Construction: Yes El No © FHA/VA: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septiq`Tank-` Distance from nearest welL_________-------Distance from foundation_".________--_____.Material-----------------------------------------_______- I -Liquid depth------------- -----------Capacity !5 No. of compart lents-------------------------Size----------------- - _ 4-___.._ Distance to nearest lot line__"-----. Disposal Feld Distance from neare t welL__-"�__Distance from foundation.___, __7 ` en t}, of each line_ D-._ -h' Width of tren6l.21_ --._.--.--------------------- � Number of lines- _ ______--7 ----- 9 it i Type of filter material_ & �_ __ epth of filter matenal_. "-`___Total length,----------------------/ Seepage Pit: Distance to nearest we1!____ ---------Distance from fo ndafion_�© jD's nye to nearest lot Ike""e �___---- Q _Linin material_ -Size: Diameter2 _---------pepth�CC�� ` "--- [q�'. Number of pits-�.�---------_.- g 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------------------------------------------ ❑ rest lot line--------- ------------ - -------- --•-------------------- Distance to nearest --------� -- Remodelin and/or repairing (describe)-----------------a- ---------� ------ - ---------- 9 -----------------------=•--------------------- ___________________________________________________________j}_________________.-______________._—________-.__________--______ --- --------------------------------- - - ------------------------------ ---------------------------------- Y I hereby certify tha+ I have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, State laws, and rules and r gulations of the San Joaquin Local Health District. t0ya=mmmd;�qr Contractor] (Signed)--------------------------- - -------- By:--------------------•----- -- ---- - -- - ------(Title)......y�y (Plot plan, showing size of lot, location of system in relatio wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTEp BY__."__ -_ / _- -- - - - ----- --------- - ------------------- DATE------ -� Z_ ----------------------------- ---------------- -- -- REVIEWED BY-------------------------------- -----------------:-------- ------------------- ------------- ----------- DATE-------------------------------- --------------------------- ' PERMIT ISSUED___________ _ ----"-----.-. - ---- ---- - DATE.------------------------------------------------------------ BUILDINGAlterations and/or recommendations---------------------------------- ----------------------------------- ---------------------------------------------- { - - -------- '-------- - -- �----------- - --- --------------------- -------------------- --- --- ------ - - ` e - r�7- -4------------- - - -- - ---------------------------- ......... Date------------------------- --- ---------- -- -- ---------------------------------- FINAL INSPECTION BY-------- - - --- --- - yC- - - I S N QUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.0 O.