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FOR OFFICE USE: 4a: ___________________----_-------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. •'�_fJ_ - _ ' -------------- - --------------- -- -•---- l (Complete in Duplicate) -- This Permit Expires 1 Year From Date Issued Date Issued ___ _` 1-__ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the wk herein de/sc_rbe ,pfThis application is made in compliance with County Ordinance No. 549. ��sG��,Q� JOB ADDRESS AOF- ND Owner's Name---- - ,r~ i. _, �r.- .-. / �ra� -------------------------------------------------- ---------------------- Phone----------------------------------- Address •�� ._----------�� -p— ---------------------------------------------- �`�,7 Contractor's Name----------- l� � ------------------- --------------------•-------•------------------------ Phone.----•-•-------•--•--•-•--••------• Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: __' Number of bedrooms `^-_ Numbef of baths _l_- Lot size_______________________ ____ ` Water Supply: 'Public system E] Community system E] Private 9?'15epth to Water Table fti. Character of soil to a depth of 3 feet: Sand .Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe E] Harcl n g— Previous Application Made: (if yes date----------.---------) No ® New Construction: Yes ga--no ❑ PHA/VA: Yes ❑ Nr�-r ,;_ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) .n. Septic Tank: Distance from nearest wel-me/.-C/__.__Dist e fr/om foundation- /lL� :.-.----_-- No. of compartments..__ ._._..___�.__Size �2_- -Liquid de`th__ P y�- -- i Disposal Field: Distance from nearest wellAro.-___._Distance from foundation_ZQ____•-- Distance to nearest lot lines ---------- ®� Number of lines-----__-_ -1,_... _.__.._ Length-of each line____��__�__ .Width of trench_�-.`______________________ ' � ziE ..�s 7ype of -.._Depth�of filter matenal___.�� . ___Total. length_._ --__________________________--__ i- - • . d s Seepage°Pit: - "�"`"Distarice to nearest Il.... -_�_ -__----Distance fr m foundation---$_-------------.Distancjp to _ _ - o gearestJ.Qtline-_._ �,�, ®� dumber of pits__ \:'. - --.Lining material _ _49 ra_ _Size: Diamete _,rY.��D.Depth __7 --�--..__ � Cesspools Distance from nearest dell-----------------Distance from foundation --- - ---..Lining material__ _________________ Li uid Capacity gals. Size. Diameter Depth ------------- ----- ---- q P y -- ------------ -- g Privy: Distance from nearest well __ __________________ _ Distance from nearest building_____ -._--__. ❑ Distance to nearest lot line.----�------------------- ---- --- ------------------------ Remodel hg and/or repairing (describe --- ------------ ---------=------ d----- ------= ------ ----------•---- ----- --• .x �- _ .. t 1 __. _ _ --------------------------------------- ------------ = Y;-----------------------------------------------------------•--------- I hereby certify fliafThave prepared this application and that thee work5will be done in accordance with San Joaquin County ordinances; State laws, and rules and regulations of the Sen oaquin Local Health District. (Signed)---- ry: - -- -------------- -------------- ---- -------------------- or Contractor) Y:-------------------- ------------------------------------------------------ -•--•------ -(Title)-- ......... - (Plot-plan, show.ing s ze Of-lot,-location-of system-in_ ion;to-wells, uildings,-etc.,,can-be..p aced,on�reverse-side}.-- y- — FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- ' �'� t=- --------------------------------------------------------------------- DATE__",x ? 2Z REVIEWEDBY------------------------------------- -------------------------------------------------------- ------------------------ DATE----------------------- BUILDING PERMIT ISSUED -------------------------------- DATE---------------------------------------------- � Alterations and/or recommendations:--.-------------- ------ -----------------------------------------•-----------•--•---------------------------- 1 -- ------- - ------ ---------------------- -------------------- - - . -_- - ------ I � ----_r .------------------- --------- ------------------------ - - t -- ------------------- --- --- ----------------- -- -- -- ------------ --------------------------------- --- -- ---------------------------- ---- l . FINAL INSPECTIONY �--�- - -�---- , . ..... � Date.-.-.-.-.--- r - --��=- - - SAN JOAQUIN LOCAL HEALTH DISTRICT i Ei 1601 E.Ha:ellon Ave. 300 West Oak Street Y 124 Sycamore Street 205 West 9th Street a, Stockton,California Lodi,California Manteca,California Tracy,California - r.a.cn.