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OR OFFICE USE: R / �5----------------------��------. f _ APPLICATION FOR SANITATION PERMIT Permit No. _.,ltl��.... ---------------------------------- ---------- -- ---------- ---------------------------- (Complete in Duplicate) Date Issued ._.Vx This Permit Expires 1 Year From 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 AND LOCATION C ,r ------ �-'-----------�--�� - ---�-�----------------------- E Owner's Name-------------------- Y f---- '------- %1 ---------------------------- Phone-540;2-_gN�_73.----- Address---------------------------------"-- 7- --- '_�. �� 1 7 ,CY T----------------------------------------------------------------------------- Contractor's Name-------------------= �L` j iV '----------------------------------------------- Installation -------------------------------------------Installation will serve: Residence [ij/Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _'i_ Number of bedrooms ----�_7—Number of baths .... _. Lot size .. --_ ----A _---_......_ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Saridy Loam ❑ Clay Loam Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: [If yes,date-.------------------I No P3-" New Construction: Yes ❑ No D-�FHANA: Yes ❑ No [r 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----------------------- Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line..------....___.. i ! ❑ Number of fines-----------------------------------Length of each line.-----------------------------Width of trench_-----------.-------------.------ N Type of filter material-------------------------Depth of filter material......................Total length.....-..........__.-----..-..-..._..------ N Seepage if: Distance to nearest well------ ------------Distance fr foundation-./-19-_--.....Distance to nearest lot line-_��._-/. J V Number of pits......-_-..----.-Lining material--- Size: Diameter_33--- Dept h...�.��'-....- Cesspool: Distance from nearest well__-------------Distance from foundation.------------------ Lining material.._.------_---_---.--..--.--_.---. �) ❑ Size: Diameter--------------------------------------Depth---------------------------------- -- --------------Liquid Capacity- --------------- ----------gals. < Privy: Distance from nearest well------------------------------------------------- from nearest building-----------------------------.-.---.-----. ❑ Distance to nearest lot line--------- ---------------------------- --------- ----- Remodeling and/or repairing (describe): �� -------- f , f'� •--•--------------•-------------------------------------------------------------------------------- ---- ------------------------------------ ----------- ------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------ ----------- ------------------------------- -- ---------------------------------------------------------------- ------------------------------------------- -- ----------------------------------------------------------- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws ules and regulations of the San Joaquin Local Health District. (Signed) e _' wner nd or Contractor By:------------------ lL�. - � t --.------------------------------------------------- ion ----------- (Plot plan, showing size of lot, ocatian of s stem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY �� .-------------------------------- DATE �jl �`�' � rte'--------- - REVIEWEDBY------------------------- ------ ----- ---- ---- -- ---------- ------------ --------------------------------------------- DATE------------------------ -------------------------------- BUILDINGPERMIT ISSUED------------------ --------�-------- --------------------- ------------------- DATE------------------------------ ---a-------------------- Alterations and/or recor>amendations:- __�' -------- ----- ' ` --�----- Z ---- ----------------------------------------- ------------------------------ --------- --------------- ------- ----------------------------------------------------------------------------------------------------------------------------------------------------------- -- ----------------------------------- ------------------------------ --------------- FINAL INSPECTION BY:. -----•--_ ----- __-------- Date..... / AOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California