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vi r[t.[UJt~ t 1 --- ------------ --- ------- # r - --- --- - ------ __---.-____. APPLICATION FOR SANITATION PERMIT Permit No. .......... / .-/- - `_•`• , -` 4 _. (Complete in Duplicate) This Permit Ex fires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health ealth District for a permit to construct and install the work herein described. This application is ma a in compliance with County Ordinance No. 549. , JOB ADDRESS JI OCATI / F Owner's Name-- ---�-� ----�-��.:�#--------�� FI . - -R°_ . - Phone eAddress---------RY -------------------------•-- Contractor's NameN- _--------- -- -----------------• - ------• ' -----•-------------------•------•- --------•------- ------------------------•----------------- ------- .... Installation will serve: Residence Apartment House ❑ Commercial Phone------------------__--_-- I 1 ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ,Number of bedrooms 3-. Number of baths _ s �� Lot `sizeCl ,l > G_ = Water Supply: public system ❑ Community system ❑ Private 9 I3epth to Water Table/�- ft. f Character of soil to a depth of 3 feet: Sand 'Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan Previous Application Made: (If yes,dOte----------------____) NoEi'lNew Construction: Yes N ❑ TYPE OF INSTALLATION AND SPECIFICATIONS - on: ❑ o � A/VA: Yes No "`[Nb septic ta`rtk or ces`speol"permifted if`public sewer is available-within"200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation------__-___-- ,...�� . J,;_.y �.,,. ..,�.�,.•„•a -----.Material------ ------- t �-- No. of compartments---�- ---- ------- --- -5rze----...---- ---•=-- -�-f---Liquid depth----- �----- Capacity t ---------- -- ----------------------- Disposal. Field: Distance from nearest e!I__ i _--_Distance from foundation_-JO �X��/aDistance to nearest of line-- -___- rte tom- NumberEof lines----------�_§-�.-------�--"-Len ith of`each fine_,. -_ � �- j tAP D' }" 9 s _ Width of trench . +- _— -� Yp p filter material...__--. .:_Total length----------- - T e_of�fiiter material__ - ��--__°[}e th'af' See a e Pit: .,� -- ❑p g Distance to nearest well-___--_--_---_-___-Distance from foundation----------------'".Distance to nearest lot line____" --_______• J Numberlof pits----------------------Lining material--_-----•----_----_--_- ize: Diameter------ --� ---------Depth------Depth_------- ---=--• Cesspool: Distance from nearest welL-- _._ Distance from foundation_- ----------------Lining material________________ ` i ❑ Size: D;ameter._=;=" '=-. f Depth:- --------- . rtLi)qu;d Capacity -- gals. Priv Y Distance from nearest well---------- --- =---- -- Distance from earestlbuildin t Distance to nearest lot fine__-----_ °" g------------------- El ---- ---------------------- - - - -------- Remodeling and/or repairing (describe]:-___-_____-_-.•____ 1 -• -----------=------ -------------------------------------:-1-A---- - }------------------------------- ---------- ---------------------------------------- - ------------------------=== '"E -----------•---------••-------------------•---- - -W- Y-------_----=--=--- , --- ---- I s -, � i --------- e---G-------------------•-----------•-----------•------------------------------------------ --------" I hereby certify that I have prepared this application arta hat the work will be done in accordafte with San Joaquin County ordinances, Stat s, a ules nd regulations f the San!Joaquin Local Health District. (Signe --- •---------- ��..--_=-wgy ��.r __-•� �� ----------------------------- ----- --- -- --- --(Owner and/or Contractor) �r ( p of Ian, showing size of lot, location of system tnsrelation to wells\b�ildings!etc., can be placed on reverse.srde). r .� , t. t FOR DEPARTMENT USE ONLY- r APPLICATION ACCEPTED BY---- is. s.ac_-,•,-------------------- '= ' _ REVIEWED BY.. -- - --`--- DATE-------- � " ._ ------------------ DATE" --- ----------------------- --------------------------- Alterations ---` BUILDING.PERMIT ISSUED_____ _____._____-- - -__ ----- --- -- �'-`DATE.. , . ,_, A terations and/or recommendations::_-�-"^.:'_-_:`-'__-:__-"�- � - ' =z]-G��.IVO PRaf- ---------------------------------- -------- --- -- -------- _---- -- ----- ___....--"-..--_ I ______________-_--___--.-_-..______-__.--_..__-_--.-_--__---._--.__--__- ------------------------ -------- ---- --------- ------------------------- FINAL fNSPECTION- Y: sJ = - Date (li SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E.Hazelton AvQ. 300 West Oak street • 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California