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rvK VrrlCt USE: r APPLICATION FOR SANITATION PERMIT Permit No. ___171�G _ r` p (Complete in Duplicate) k k This Permit Expires 1 Year From Date Issued Date Issued 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 O�C'ATION � -- - Owner's Name_____ - ---------------- F Address . ,t / ------------------- ----------•--- - ---------------- --------- Phone--------------------- ----------- ----•------------------------•-------------------------------------------------- - ---------- ---------------------------------- Contractor's Name...--__.__` �- ,---:;e- •- - --------------------------------------- Phone.---,,----------------------------- Installation will serve: Residence Apartment House ❑ Commercial F] Trailer Court-❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms ---_ Number of baths __ �_ Lot size . ..- J X .------•------------------------ Water Supply: Public system ❑ Community systemF1 Nate ❑ Depth to Water Table A�w Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe W-Hardpan ❑ Previous Application Made: {lfyes,dale------------.-------) No [Lff---New Construction: Yes ©"No ❑ FNA/VA: Yes Z --No TYPE OF INSTALLATION ANP.,SPECIFICATIONS: F1 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tek: Distance from nearest w 1...--—-----Distance from ounclation_.-.-I f Material V�f No. of compartments... i� —•� f Sizer �l �1� �quid depth------14---- ---------Capacity- Disposal Field: Distance from nearest well__...------Distance from founda#ion__'1V_ � r...._.Distance to nearest lotER--- Number of lines._._____---]--- - -Length of each line....7�_.__ ___ ,___.Width of trench -------------------- -- ---7 ------ Type of filter material.�` yt--_--Depth of filter material..-f�_- '` { YP __ _ _ -_..Total leng#h-..fes _____ __ Seepage Pit: Distance to nearest well-_ bistance fr m fo ndation... `��---.Diance to nearest lot line.. W Dumber of pits.-..-_ ,______-__..Lining material._ Size: Diameter._ Depth Cesspool: Distance from nearest wefi--------- ------Distance from foundation-----.--------.___..Lining material.....__ ❑ 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 --------- Zp - -_ � ..- -------- -----= ----------------------------------------------- --------------------------------------------- ---------- ----------------------- -------------------------------------------------------- -------------------- ------------------------------------------- -------------------- -------F•-------- -----------------------------•---------------•-------•------------ ----•----------------------•---------------------------------•---•------------ { - 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 t e San Joaquin Local Health District. (Signed)-------------- YT�/ � � Contractor) By:----------------------------- - O rrdfor C actor a Title { (Plat plan, showing size of Rif location of sys+em in` tion to wells;"buildings,etc.�can-be-placed-on-reverse side). I _FOR DEPARTMENT USE,ONbY APPLICATION ACCEPTED BY.-.V. - --------------- ------------------ DATE % -- --------�� -- REVIEWED BY ------------ - ----------- ---- ---- -�----�--------- - ---- ---------- -------------- DATE------------------------- ING PERMIT ISSUED -----------' ----------------------------------------------------- DATE Alterations and/or recommendations:.- /�}Y-- cJ,_� ---- --------------------- _- -- ---- - ---_'- �.�.----- -� ..moo -�.,.�� _ �` - - --- ---------•,------------ ----------------------•-------- ------------------------------------------------------- - ---------------------------- -------------- - --------------------------------------------------------------- - FINAL INSPECTION BY:.__ 9-----.-.. Dete---------�� T---------- ---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West oak Street . '�\ \ k—11 A \J 4 Sycamore-Street � IN7 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California I