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FOR OFFICE U5E: 1c 3 ------------- APPLICATION FOR SANITATION PERMIT Permit No. ..:_.a 34 - -- ------------------------------------------ ------- ---------------------------------------- ------- (Complete in Duplicate) Date Issued ---------------------------------------------- -- ------- This Permit Expires I_Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct a install the work herein described.,.", This application is made in compliance with County Ordinance No. 549. --------------------------------------- ---------- ---------- - --------------I------ ------ JOB ADDRESS AND LOCATION---- - -- ------ kk N '0 Z — - Phone.----------------------------------- Owner's Name-------------4 ,.99_rVZ1e----------------- ---------------------------I----------------- Address--------------------- --------------------------------------------------------------------------- ------------ ---------------*---- --------------------------------- -------- --------------------------- V11- -----------------_- --- ---------- ---- -------- Contractor's Name- ------ ------—z".11-0-len-hone----------------------------------- 2 Installation will serve: Residence E] Apartment House El Commercial ;& Trailer Court E] Motel D Other ❑ Number of living units: --.----Number of bedrooms __/--- Number of baths Lot size ---1,6D-- ---Z4?-c------------------------- Water Supply. Public system Ej- Community system El Private)< Depth to Wafer Table tl ft. Character of soil to a depth of 3 feet: Sand E] Gravel [] Sandy Loam E] Clay Loam E] Clay ja Adobe E] Hardpan E] Previous Application Made. (If yes,date--------------------) No [X New Construction Yes E] NojR FHA/VA; Yes D N 0,A TYPE OF INSTALLATION AND SPECIFICATIONS: f 1, (No septic fanL;or..cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well___-_.�----/Distance from - --- - ----- -------- No. of compartments-- -----�----------Size----/*'__k_0_t-*'6:7_Liquid depth------. _Capacity---4 .-Dislance from foundafion_Z0__-'.__.Disfance to nearest lot line Disposal Field: Distance from nearest weI1___,1:5 _ 04.0— -------- Number of lines------------16... Length of each line--- ---------------Width of ------I------ -------- VWX. Depfh of filter material.... Total length--_---.. ------------------- Type of filte'rimaterial---:5;i ............ Seepage Pit: Distance to,,nearesf well----------------------Distance from foundation---_---------.--___Distance to nearest lot line-- -------------- F1 Number of pits----------------------Lining material-------- --------Size: Diameter------------------ Depth------------------- ------ I I Cesspool: Distance from nearest well-----------------Distance from foundation-------- - ---------LWng material_-..--------__-___._---.---------.-_. ❑ Size: aterial_--------------- ------------------- Size: Diameter--------------------- - --------------Depth- ------------------------ --- -----------.----------Liquid Capacity----------------- ---------gals. Privy: Distance from nearest' -well--------------------------------------------------Disfance.from nearest building-----_._____-..----.------_------..---_. ❑ Distance to nearest lot line---- ------------- - ------- ---------------------------------------------------------------------------- ---------------------_----------- i " '03�. Remodeiiing and/or r4paii?ing4(describe):-------------16iev;ez)- ---- ---I---------------------------------------------------------------------------- iiii �1_ l - -- ------ --------------I---------------------------------------------------------e--------------------------------- ------------------------------------------------------------- ---------- ____ _X ifII ---------------------------------------------------------------- ----------------------------------------------------- ----------------------------------------------------------------------------------------------------- ------------------------------------ -------- 111ilf- 1- - - --- - -------------------------------------------------------------------------------------------------------------------------------- ----------------------- I - _ I hereby certify that I I ihave ii.prepar I ed this application and'Wa't the work will be done in accordance with San Joaquin County ordinances, and regulations of f, San State>I�d'rul.es uin Local Health District, 19 r and/or Contractor) -------------- (Signed)-------------------- --- -- - ...... -------------% i- 4 ---------- By:--------------------- 4------ -------- ------------------------------------------------(Title)----—---------------- ---- - ---------- ---------- - ---- - - io , X. (Plot plan, showing size of lot, location em in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- - --- ---------------------- ---------------- DATE----- - 6-G--- ----- ------- -- - ------------------------ - REVIEWED -------------------------- BY----- --------------------------_------ --- ----------------------------- ------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------- ----- -------------------------------------------------------------------------------- DATE---------------------------- -- ------------------------------ Alterationsand/or recommendations:------------- --- ------------------------- - --------------------------------------------------------------------------------------------------------------- ------------------------------------------ ----------------------------I--------------------------------------------------------- ---------------------- ----------------------------- ------------------------- - ----------- ----------------------------------------------------------------- -------------------- ------------------------------------- ------------------------------------------------------------------------------- V --- ------- ------------------------------------ --------------------------- -------------------- --- --------------------------------------------------------------------------------------I-------------------------- - -_ ---------- -------------------- - --- ----------- ----------- ---- - ---I----------- -------- -------------------- --------------------------------------- -------------------------------------------------------- 7 'SIZW FINALINSPECTION BY:- --------- ------------ Date------ -- -------------------------- ---- --- ------------------ ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stocklon,California Lodi,California Manteca,California Tracy,California F.R.00.