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FOR OFFICE USE: ----------------- ---------------------------------- - -------------------------------------------- ----------- APPLICATION FOR SANITATION PERMIT Permit No. 190:. -.• -------------------- ---- --- ---------- (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 constru.Ef'and install the work herein dgscribed. This application is made in compliance with County Ordinance No. 549. 6-773 G - SOW 4k'�, Q �,I JOB ADDRESS AND L CATION 1� ------j-�'ORT J--1V -Z '�"'"`zF• >f -' / ' ------ ------- ��j�[ _ ��10- T®!�i --------- Phone------------------------------------ Owner s Name---------------------7------ ------------ r f -+ } Address-------------RTE_:-_ 3------ b!-X----'-.-•14-----------1-37�- ----------I TC -_, ------------------------------------------------------- -------- Contractor's Name------C - -r-}- -.F_� _ ----- phone----------------------------------- Installation will serve: Residence [5—Apartment House ❑ Commercial [j "Trailer Court ❑ Motel ❑ Other ❑ i Number of living units: .--.- Number of bedrooms _-3- Number of baths -_ -_ Lot size — ------- -------- --------------- Water Supply: Public system ❑ Community system ❑ Private ®Depth to Water Table - - ft, Character of soil to a depth of 3 feet: Sand Er Gravel ❑ Sandy Loam ❑ .Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date-______________-.r-) No ®-- New Construction: Yes E] No ❑--I`HA/VA: Yes ElNo [ � TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) STI k- Distance from nearest wek-----------------Distance from foundation--------------------Material----------.--------------.----------..----..----- �� _ Septic Tan No. of compartments------- ------------ Size-------•----------------- -----Liquid depth ---= ------------------Capacity----------------------- Disposal -------- - - ----- Disposal Field: Distance from nearest well 5 ----Distance from foundation----1.4?--._.-_-Distance to nearest lot line_- © Length of each line_�a-` _� _-.-.Width-of french--------- t-,-�----------------_ ,TfIV6r— Number of lines___-.-`�--------------- -- q t Type of filter material---. 1C--C�4___Depth of filter material-------1--I- ..Total length.......NA-V-------------------------- V Seepage Pit: Distance to nearest well-----.------------- from foundation----___---------Distance to nearest lot line----------------- 0 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------------------------------------------ El _.__---------------------------- ------[l Distance to nearest lot line- ------------------------------- ---- ------------------------------- --------------------------------------------------------------- Remodeling and/or repairing (describel:----------------------------------------------------------------------------------------------------------------------------------•-- ----- ---------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------ ---------------------------- ----- - ----------------•----------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 regulations of the San Joaquin Local Health District. O — , �Lj ---------(Owner and/or Contractor) (Signed)----� ..-�-- �-�-------,-- -- --��----=-- -- --- - -------- --------------------- By:----------------------------------------------------------------------------------------------- ---------------------------------(TitI le)----------------------------------- ----..... ---- --------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). id FOR DEPARTMENT USE ONLY-" APPLICATION ACCEPTED BY---------l_-(-_-- -`.G - - DATE-------- -"--L_J--.( S_.------------------ - ------------------------------------------------------------------- REVIEWEDBY------------------------------------- - ------------------------------- - ------- ---------- --------------------------- DATE---------------------------------------------------------- - BUILDINGPERMIT ISSUED----------------------------------- ------------------------------------------------------------------ DATE------------------------------------------------------------ Alterationsand/or recommendations------------------ --------------------------------------------- ---------------------------------------- ----------------------------------------------------- --------------------------------------- -------------------------------------------- ----- --------------------------------------------------------------------------- ---------------------------- ------------------------- --------------------------------------------------- ------ -------------------------------------•---------------------------------------------------------------------•---------- ------------------------------------- ---------------------------- ----------------------------------- T-------------------------- ------------------------- Z ' - FINAL INSPECTION BY:- -- Date--- -.� �' �~�---------------------- 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 r.P.ca.