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FOR OFFICE USE. 11-651 ------------------------------ ------------------------- APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) __..__ This Permit Expires 1 Year From Date Issued Date Issued _fj�-_a�5� 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 Ordin ce No. 549. 17k,171r SMR JOB ADDRESS ANIDTIO,,[N----- ,i � 3 � Owner's Name----------- �� F — -------------------••------- -------- -- ----------- Phone-------------------------- Address-----------------714 _[� 8� l*)/ -- --------------------------------------------------------------------------- Contractor's Name----------- : v-1149------ _IeZ - ------------------- ------------------------------------------------------------- Phone--------------------- _..---------- Installation will serve: . Residence Apartment House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _l_____ Number of bedroom --- ------- Number of hs�:_-- Lot size _-� �_--�''-------------- -------•- .- Water Supply: Public system ❑ Community system ❑ Private Depth to Water TableClfft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sand— oam ❑ Clay Loam ❑ Clay ❑ Adobe ardpaann ❑ Previous Application Made: {If yes,date-----------,......--} No a New Construction: Yes No ❑ FHA/VA: Yes ©11No Cl TYPE OF INSTALLATION AND SPECIFICATIONS: * ; (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tpk-- Distance from nearest well---_ST_!---Distance from foundation__._ ._--Materia!_..__ ._ .- ----PI-e-47 L+�K No. of compartments ........... � p �-----�--Size- Liquid depth--------- /--------------Capacify.-An-�----�-- � Disposal,5eld: Distance from near st well._15=+___Distance from foundation_!._..____ .Distance to nearest lot line _. Number of lines___ .-�_.______,� length of each line___7y�--Y' s _._.Width of trench_._c4_7,--_�______---------- Type _________ { T e of filter material__1�2._ �D-�_De th of filter material-__ - Total lenth-_ ____________________________ Seeprage�,Pif: Distance to nearest welL_ M.!�..'_______Distanc om foundation-_/* _.Distance to nearest lot line_ ____________ Number of pits__..___._..---_Lining material e, 1V_____Size: Diameter-3._ __...___Deptnc �__h'rwy(__..__ Cesspool: Distance from nearest well-----------------Distance from foundation._- ----------------Lining material------------------------------------- 0 Size: Diameter---------------------- --- Depth--------------------------------------------------- Liquid Capacity----------------------------gals. Privy: Distance from nearest well----------------------------------- Distance from nearest building_.________.-- --------------_---_.____.-- ❑ Distance to nearest lot line - --------------------------------------------------- --------------------- - ------------ Remodeling and/or repairing (describe):--------------/u-eFw- ----- k .--------S � - -------------------------------------------------------------------------------------------------------------•--------------------------------------------------------- --------------------------------------------------------------------------------------------------------------•------------------------------------------------------------------------------------------------ --------- ----------------------------------------- -------------------•--------------------------------------------------------------------------------------------------------------- ---------------- ----------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 11 ordinances, Sf e w and ru d regulations of the San Joaquin Local Health District. (Signed) kt� --------- ---------------------------------------------•------- ------.(Owner and/or Contractor) c By:------------- � �'�� i��1�.�`�� (�1 ----------------------- ------{Title)-- ��L�/�"Q.- �Z�� - (Plot plan, showing size f lot, location of system in relation wells uildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- ----------------------------------------------------------_______ __ � 1 DATE - REVIEWEDBY-------------------------------------------------- ---------------------------------------------------------------. DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------- ------------------------ --------------------------------------------------------------- DATE-------------------------------------------------------------- Alterations and/or rete mendations------------------- ------- ----•-----------------1---• ----------- --- ---- ---------------- ---------- -- --- --------------------------------------------------------- --------------------- - -- ------------------------------------------------------------------------------------------------------------------ FINAL. INSPECTION BY:..---- ---------- ---------------------- Date---------- - --- --- --------------------- OAQUIN LOCAL HEALTH DISTRICT 1601 E.Na:ellen Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.r;R. .. i