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FOROFFICE USE: �J ------------ ---------- --- -------- --------- -- APPLICATION FOR SANITATION PERMIT Permit No. .__ �. .�. ---------------------- ------- ----- ---------k------- (Complete in Duplicate) __. __ ..__. This Permit Expires 1 Year From Date Issued Date Issued ---- Application is hereby made to the Sen Joaquin Local Health District for a permit to construct and install the work herein described: This application is made in compliance with County Ordina No. 549. JOB ADDRESS AND LOCATION , ` Owner's Name----------,� ------- V ------------------------------------ Phone.41.7 QT• __.. Address 's�" � Q'Q---- --- •--- - ---- �+ -----------------------------------------•- -----------•--42 �_7fit-- Contractor's Name-------------------' � 1'�---P---Pu5_t4---- --1A -C, Ite Phone_66� ,!�'7 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1_____ Number of bedrooms _.i__ Number of baths 2.--_ Lot size _14p_ x___ �___ ____________________ Water Supply: Public system ❑ Community system ❑ Private X Depth to Water Table _4-O ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe,, Hardpan ❑ Previous Application Made: (If yes,date--------------------) No %_ New Construction: Yes ❑ No W FHA/VA: Yes ❑ No j< TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 fee+.) Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material____..._____._.._______________________---.--.-_. ❑�f t5,t/►U(: No. of compartments------ --- --------- -----Size--------------•-- -------------Liquid depth---------------- ---------Capacity------ -------- ------- IJ* J# Fiefd: Distance from nearest well--Sa_.___-._Distance from foundation__1�--.._..---.Distance to nearest lot line.-�--.._____ Number of lines____r 1�.C_�_�-�_..._-___- 7.Length of each line___ '_-______ ____________Width of trench__.�¢_rl __--____._.--__-._-_ Type of filter material- 01_�`_ �JC��•_.Depth of filter material---1.g....._........Total length------Z,�--------------------------- ♦ Seepage Pit: Distance to nearest well---- Distance from foundation_Z-___--------Distance to nearest lot line..�_�___.._ i Number of pits---�1.�rb _Lining material_j�0-0sr.._.__.Size: Diameter_6X_e_)(./,9-_.Depth--_.�p.�--------------------- 0 Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- J ❑ Size: Diameter----------------- --------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. PrivyPriv Distance from nearest well_____________________ ---Distance from nearest b0clin ❑: --------------- -------------------------------------------------g------------------------ ---------------- Distance to nearest lot line__.___._______________________________________ �O Remodeling and/or repairing (describe) -�-- ---------•---------------------------------- ------------•---- -----4-� . - ,' !� I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laptsandSrules andregulationsof the San Joaquin Local Health District. (Signed)--------------------------A_____--- �"� �` 5- - -- _--C-1-+----- '--------------------- - ------(Owner Td/or Contractor) (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placeg on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTEDJ� -------------------------- - --------------- DATE---»��-'--�� f--'---��-- ------------------- REVIEWEDBY----- - ------------------------------- ----- - -- ----------------- ------------------------------=------------------------- DATE----------------------------------------------------------- BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE-------------------------- ---------- Alterationsand/or recommendations--------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------•--•--- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --- ------------ ------------- --- ---- ------------------ -------- -------- ------------------------------------------------------------------------------------ -------- FINAL INSPECTION BY:... - --CL --�C ._� _ `"� .G Date---------------------- ----- Ca s SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazetton Ave. 300 West Oak Street 124 Sycamore street 205 West 9th Street �k Stockton,California Lodi,California Manteca,California Tracy,California