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r /rUKOFFICE USE: -� 3_o APPLICATION FOR SANITATION PERMIT Permit No.------ - .� „ {Complete in Duplicate} - ----------------'--- This Permit Expires 1 Year From Date Issued - Date Issued .// �.f Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descried. This application is made in compliance with County Ordinance No, 549. 97 JOB ADDRESS AND LOCATION_ p. _--_ " _ -------- ------------ �- ------------------------------------ Owner's Name--------•�'/``1 Ifs �A _" '.."'" �. Jam- _� I -------------------------------' Phone. ----------------------- Address------------- --a_,0-e,.. _._. Contractor's Name--------- _ --------------------------- •--------------'- ----------------------- ---------------- Phone Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ , Number of living units. -,-- Number of bedrooms Number of baths _/--- Lot size ` Water Supply: Public system ��"X"/��--"----"---------------- + system m J2' Community system Private El � Depth to Water Table _At Character of soil to'a de%pth4 ffeet: Send ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ i Previous Application Made: (If yes,date.___._---_____ - .-"-) No ❑ New Construction: YesNo � TYPE OF INSTALLATION AND SPECIFICATIONS: ❑ ❑ PHA/VA: Yes ❑ No ❑ (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tan ) Distance from nearest well----------------- Distance from fou'ndation_'_s__'_______�.Material___.__-"________-__""_- - �� :w� No. of compartments--------------------------5ize------••--'--------------------- -- -' Li Liquid de th---------------- --------Capacity-•---------:----------- Dis posafrField Distance from nearest well__________________Distance from foundation______._}_p. `'� _.__Distance to nearest lot line_______"__..____� ��'� Number of lines-_ ___ -____""-_____"_""-__ _Length of each Ime-----------R- ---------------Width of trench------------------ -Type of filter materia!______________________ Depth of filter material______-_--=__ ---- --- --�--.Total length------------------------------------------- I O Seepage Pit: Ds#ante to nearest wel!________'�`- _ Distance from foundation____ n?4._ ---Dist`;r ce to nearest lot line-, ®� Number of pits. f-.__--------Lining material__ _ .K __ ...Size: Diameter__ �� ---Depthoqvl--------------- ------ {d t Cesspool: Distance from nearest well________________ I Distance from foundation..._____-�.-",___Lining mat6ria)------------------- - 171 Size: Diameter--------------------------------------Deth-------- t____-Liquid Capacity gals. p -- ----- ----- - rivy: Distance from nearest well-___-r.."-..._""-__ " -- .Distance from nearest buildin Distance to nearest lot line..._."""__._.--------------------------- ----------------------------------- ----- Remodeling and/or repairing (describe)_______________ 3 -- - -------- ------------------------------------------------------------------------------------------------------------------------------------- = ------------ --- -- --- ------ - - - ----- 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. (Signed) -------' Contractor) By:----------------------------------- Tale ------- ---------- } (Plot pian, showing size of lot, location of system"in relatio o wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----__-.C__,____ , -------------- ------ ---------------------------------- ----- DATE-----9--'--�-I ' -� REVIEWED BY `.. - ------- ---- -------------------------- --------------- DATE------------------------- -- -------- � ---------- ---------- ------ UILDING PERMIT ISSUED---------------"_-- ---------------------- ----•------------------------------------- DATE Alterations and/or recommendations_____________:______ -------- ""--""--� ---�--�- --------- -- --------------- - --------- ------- --------------------------------------------------------------------------------------------------'-----------------------'----------------------------•----------I-------••-------------------------------- ------------------------- - --------- FINAL INSPECTION BY:------ .- --- ---------- n ------ -'--' ------'- Date--------'-'-[?-'--1-�,--'-��'.- ---- �----'-- -'- - SAN JOAQUIN LOCAL HEALTH DISTRICT 0. 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Sot � � tre203 West 9th Street Stockton,California —todi,California Manteca,California Tracy,California