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FOR OFFICE-U12t:� ---- -- ---- ---------------------------____ _r"3 a--. APPLICATION FOR SANITATION PERMIT Permit No. ....1T17 _ -------------- -------------------- ------ (Complete in Duplicate) Date Issued This Permit Ex ices 1 Year From 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. JOB ADDRESS ANDOCATION_.._. _ ----� -------[�-� �d :_.-..-a!igflx / ----------------------------------------------------------------------------- Owner's Name - --- ------ Phone 0A 9 NAddress. ------ iYj ------------------------------- Contractor's Name------------------------ -•--- --- ----•------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Impartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ l Number of living units: _-_ - Number of bedrooms Number of baths _A__ Lot size _f1,�9-W 0---------------------------- Water - -_____________________Water Supply: Public system ❑ Community system �Frivate ❑ Depth to Water Table AaCft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [] Adobe D�Hardpan ❑ Previous Application Made: (If yes,date____________________) No [+�• New Construction: YesfR9'No ❑ PHA/VA: Yes g1— No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ,/' (No septic tank or cesspool>permifted if public sews his available within 200 feet.) Septic Tank: Distance from—nea'rest�w it~^-- =Distancff�Ffrom`oundatibn= - Mate ll ' - _____Z___________"--._. 'Liquid No, of��opartments_ ___________________Size:�h__ depth----- .�._. p y Ca ac=t f ___-_-- �f_ Disposal Field: Distance from nearest well......._-~-----Distance from foundation----/,t�__----.Distance to nearest lot line_ �- s Number of lines___.___-__- _"__ Length of'e'�h line____-__ ._______�______ Width of trench___�_._.�_____________"__.____ Type of filter material- ��/ k'� Depth of;filter material_-__,e_/r----------Total length-__ ___-____.___-__ Seepage Pit: Distance to nearest well_____ ----_--------Distance fr m' fou_dation______ .___.Distance to neat lot Ili e..��--_- --- [�]� Number of pits....______"____.Lining material__Ap04_ __Size: Diameter__.�Y�r---____Depth fxs -_/ 1 �_ G I Cesspool- Distance from nearest well___________ __Distance from foundation--------------------Lining material--------._ ------------.________.__. 1� ❑ Size: Diameter------ ------ --- - --------------L-iquid Capacity-.--------------------------gals, Q Privy: Distance from nearest well-________________________________________.______Distance from nearest building---------------------------- ❑ Distance to nearest lot Jine------------------ ---------- -------------- ----------------------- --------------•----------------------------------•----------- I Remodeling and/or repairing (describe):__--------------_ _� .. !! ------" ------------------------------------------ ----------------------------------------------------------------- ------ fl.. -- -------------------------------------------------- ' -------------- ------ -----------------------------------------------•-----------------•---•------------------------------------••------------------ --------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 d regulations of the San Joaquin Local Health District. (Signed)---------------------- ✓ .-- ---- -- T ___"----- ----- - -- - -- -..ar+d7lor Contractor By:---------------------------------------------------------------------------------- --------(Title) `t�.� ---------- -- (Plot plan, showing size of lot, location of system in relati o wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY =APPLICATION ACCEPTED BY-- --- ' ---6Z,-04----------------------------------- DATE------ f REVIEWEDBY------------------------------------ --- -------- ----------------------------------------------------•------------------. DATE. BUILDING PERMIT ISSUED DATE Alterations and/or recommendations:--- _'�� - `_ ----------------------------------- ----- - ------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- --------------------------•------------•-------------- - -------------------------------------------------- ----------I-------------------------------------------- -- ---- ---------------------- FINAL INSPECTION BY:_._ it -------------------:---- -------- --- --------- Date - -- _`�_____�'��`�" �'.-------- -------------- - SA-�N-JOAQUIN,LOCAL HEALTH DISTRICT / 1601 E.Hazellon Ave, 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.Ca.