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FOR OFFICE USE: ------------------------------- ------------------ ---------------------------- ---------------------------- ------- ------________________________.--.____------.-_____-----__---- APPLICATION FOR SANITATION PERMIT Permit No. . Q_ a ,42 - -- --------------------- ------------------- ------ (Complete in Duplicate) ------------- This permit Expires 1 Year From Date Issued Date Issued _Y7r2_Y_G/4" 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 AN LOCATION_. -.fY2 ----q'l,G kI .---- -- - ----- -• ---------- -- ---------------- Owner's Name - PhRne--------------------------------- Addressl -_-_l. ...I � __... -------• ------- - ---- - ------ `y"�- ------ ----- ---------------------- 41 / Contractor's Name •. ----------- -�- one Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [] Other ❑ Number of living units: I_____ Number of bedrooms___ Number'o baths/----- Lot size --------------------- Water _------_ Water Su I • Publics stem s pp y• y ❑ Community system ❑ Private Depth to Water Table _..___._ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay 0 Adobe❑ Hardpan E i Previous Application Made: (It yes,date--------------------) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material +______-_. ❑ No. of compartments------ -----------------_Size--------------------------------Liquid depth.-------------------- ---Capacity----------•----------- Dispos ield: Distance from nearest we11__c d.f_--Distance from foundation---l�..........Distance to nearest lot line_-r_I---_--.-- Number of lines-------f.---- Length of each line---/0-4-----_----________Width of trench_._�-:_�-_.-----...________-._ d a Type of filter material_______ t__.__j-----Depth of filter material-------/1- ----_.Total length--_ -_-_____---------------- "> Seeps Pit: Distance to nearest well____r1aQr____Distance from foundation--_-1d--_I-_--.Distance to nearest lot line-__ '-�__._. Number of pits- ----------Lining material------ S _--_ 5_R...... Diameter..---_.ii�OKe------Depth_z-S.`_____--___--- Cesspool: Distance from nearest well_------------____Distance from foundation------------------- Lining material-.-.-_-..._.-__----_---___.-----.-_-. ❑ Size: Diameter_------------------------------------Depth_-------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well---------------------------------------._-- -Distance from nearest building.-__-----------------------------._-_---. ❑ Distance to nearest lot'.1ne----------------------------- - ------------------------------------------------------ Remodeling and/or repairing (describe) r ------- ---- -------------- -,---`-- ----------------- ------- oe ----------------------------- --- ----- -------------------------- ----------------------------- --------------------------------------------------------------------------------------------------------------j-�---------------.------------------------------------------------- --------- - - � ---------------------------------------------------------------------------------------------------------•----------------------------------------------------------------------------------------------------------------- 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, ancletAes and regulations of the San Joaquin Local Health District. (Signed) M" a . ~fAwwet=-atsd/or Contractor-]_ By: --- -----•--- 1 - --------------------- ------------------------------(Title)-- -- ----------------------------------" -- . ----------- (Plot plan, showing size of lot, location of system in relation to weft , buildings, etc., can be placed on reverse side). i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---, �� -=-7.7 � .-------------------------------------------------------- DATE------ - REVIEWED BY - DATE------- ------------------------------------ BUILDINGPERMIT ISSUED-------------------- ---------------------------.-.-------------------------------------------------- DATE-- --------------------------------------------------------- Alterations and/or recommendations---------------- -- ---------------------------------•-•---------------------------•------------ i FINAL INSPECTION BY:. Dater �"'7 � SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ha=elton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California