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F, %jFrj,.-E: u.7r: ---------------- ---------------------- ---------------- --------------------------------- --------- ------- APPLICATION FOR SANITATION PERMIT Permit No. --------- ----- --- ----------------------------- (Complete in Duplicate) ------------------------------------------ ---------- --- & This Permit Ex fres 1.Year From Date Issued Date Issued ---- V� Application is hereby made to the San Joaquin Local Health ZZY-o Z3 District for a permit to construct and install the work herein described. This application is ma h-cpm liance with County Ordinance No. 549. rc JOB ADDRESS AND LOCATIONnw- /V/ -1A_1---- ---A 11 --- --- ------- Owner's Name ----------- ----------- ----------- ---------------------------------------- Phone----. ----------------------- Address--------- ----- -------- Contractor's Name ..1. ------------------------------------------------rl�%a_r-------------------- --------- - ----------------------------------- Phone ------------- Installs+ion will serve: Residence ;K Apartment 70L se Commercial E] Trailer, Motel E] Other El 1� , Number of living units, _4Y_ Number of bedrooms_____.N umber Of kAtk1t 1, `6 ft. Water Supply; Public system El Community system Private epth TO Water fable ----- -1 Cni I .rt M Clows Adobe k�, ,n Hardtmn 1-1 rte ',,:;iay Loam L o e❑ Hardpan [] Previous Application Made: (If yes,dote-------- No [I New Construction: Yes Ej No �A/VA: Yes ❑ No 9-111-11 TYPE OF INSTALLATION AND SPECIFICATIONS: (Nb septid-fa�rik%r cds-potl permiffdd if public sewer is available within 200 feet:) Septic Tank: Distance from nearest well__-___...__. No. of compartments------- ---_Distance from foundation-------------------Material------------------------------------------------- ------------------Size-------------------- _ -Liquid depth---------- - -----------Capacity-------------------- co Disposal Field: Distance from nearest w eil ------.. --------------------- Distance from foundai-.on--------------------Distance to nearest lot line.-______________ Sh- ❑ Number of lines "Length Length of each line..... Width of trench - Type of filter material-________________________----------Depth of filter material-_._.______ Total length--------- -------- -------- --------------------- Seepage Pit: Distance to nearest well------6�74------Distan e�fa7 foundation----ZA-------- Distance to nearest )of Number of pi x ----I------------Lining materialc__ ----Size: Diamefer/�z . --1'(12-Depfk------- -K---------- Cesspool: Distance from nearest ------------- we3--- -------------Distance from foundation--------- -- -----.1ining material__-_______________________ ❑ Size: Diameter..- ------------------ ----.---.Depth ---------- Privy:,,'❑ Distance from rearest well---------------- ---------\---------------------•------- -----------------Liqu;d Capacity------------------ ---------gals. ---- -.:._Distance from nearest building-------------------------------------- Distance to nearest lot fine________________._-___- -_ -------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):----------------------- ----------------- --------------------------------------------- ------------------------------------I----------:-------- ------------------I------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------------- -------••----•----------------------- -------------------------------------------- -----I-------------------------------------------------------------------------------------------------------- --- ---------------------------------------------------------------------------------------------------------- hat the work will be done in accordance with SanJ_o`a_quin_q'o'un+'y_ I hereby certify that I'have prepared this application and +h ordinances, State laws, andrules and regulations of the San Joaquin Local Health District. (Signed)-- -- -------- - - ---------------- -------- ------------------------------------------- ------------ I -- -----------(Owne"rand/or Contraciorl y:---- ------- --- -- --------------------- ------ ------------- --------------------- ---------------- ------- --------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---_--- __ _- --------- ---------------------------------------------------------- DATE.---- - / ' REVIEWED BY-------------------------------------------- ------ -------------- ------------- ----------- ----------------------------- DATE --------- ------- ----------------- BUIL'DING PERMIT ISSUED------------------------------- ----------------- ----------------------- ------------ -----------------I--------------------------------------- DATE Alterations and/or recommendations:___________________ __ -------------- ecommendations-------------------------------------- -------------------- ----------------- ----------I........ ----------------------------------------------- -- -------------- -------------------------------------------------------------------- - ----------------------------------------------------------- ------------------------ -------------------------------------------------- ------- ------------ ----- ------------------------- ---- ------------------------------------------------ ----------- -------- ------------------------------ ------ -------------------- -- -----I--------------------- -- -- ----- --------------/-------- ----------------I------------- ------_----------__------ - - -------------------------------------- ----------- ------ ----------------- -- ___ __ /�,I il 7- ---------------------- --------------------------------------------- ------------------ ------- ---------- FINAL INSPEC - - ---- ---- -------- Date_ ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxeltan Ave. 300 West Oak Street Sycamore Street 205 West 91h Street Stockton,California Lodi,,California 124 S Manteca,California Tracy,California F.P.C:Q.