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FOR OFFICE USE: ----------------- - ----------------------.----- / ____________________________________ ___--------------- APPLICATION FOR SANITATION PERMIT Permit No.11-5P --------------------------------------------- ---------- {Complete in Duplicate} _ . This Permit Expires t Year From Date Issued Da+e 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__-F_-_-__ - 3.- - /!/ 1�/6'--------------- - Owner's Name-------------- ----- Phone- -~ - --' .moo - �/--------��-�/tib----------------------------- - ------------------------------- �`?�-/�-------- Address7-:54,3--V_, -- Contractor's Name-------'------ ,------------------------ Installation will serve: Residence [] Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ i Number of living units: __f_._ Number of bedrooms ___2 Number of baths _/.__ Lot size ____Z4 fes_XI, ________________________ Water Supply: Public.system ❑ Community system ❑ Private ��Depth to Water Table Z�ft, y Character of soil to a depth of 3 feel: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ©-'Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: [If yes,dote_________________} No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: R (No septic tank,or cesspool permitfed if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation-------------------.Maferiaf___.____'________________________________________ i ❑ No. of compartments--------------------------Size-------------------_------------Liquid depth-------------------------_Capacity-.............--- Disposal Field: Distance from nearest weli. � Distance from foundation_ . ______Distance to nearest lot Number of fines----------<_.__.___ ___________Length of each line_____.0_6?---------------Width of trench__. "' '�' Type of filter material-___ Q �/_Depth of filter material_/ f�_________._Totaf length---- Seepage Pit: Distance to nearest well----------------------Distance from foundation-----------.........Distance to nearest lot line____.__---____.__ �y ❑ Number of pits---------------------Lining material----------.-----------Size: Diameter.-__.'--------------..Depth---.______________-____-.------ Cesspool: Distance from nearest well--------------_Distance from foundation--------------------Lining material___.-._________________-.________._. ❑ Size: Diameter------------"'j----------- - -----Depth- ------ ------------------------. - ------Liquid Capacity •--------------------------gals. Privy: Distance from nearest well______________________________ ----------Distance from nearest building_.:._-_:____________--_________._.__._._. ❑ Distance to nearest lot line.--- - - Remodeling and/or repairing (describe}: l _ .1..�_�l�jl� �!��t�N ------------------ ----------------- - --------------- ------ ------------------------------------ t ------ ----------------------------------------------------------------------------- ------------------------- -------------------------------------------------------------- --------------------------------------------•----------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State lawsand-rules nd;regulations of the San Joaquin Local Health District. (Signed)------------------------- -- X �5 Ow er and/or.1 /�l - / Contractor) By: t �P ---- -----=- --= -- ----- ---- --- ----- (Title) r `' (Plot plan, showing size o ot, location of s tem in relation to wells, buildings, etc., can be placed on reverse side). 1 I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- :- -� ' �-�.�4_� ---------------------- DATE---- REVIEWEDBY---- ------------------------ ------------ -- ----_ - ---; ------------------------------------------ DATE------- BUILDING PERMIT ISSUED--------------------------------------------------- ------------------------------------------------ DATE - Alterations and/or recommendations:____________________ _ •i ------------------------- I -------- ----- ---------------- - ----- ---- - -----------------------•------------------------------------------------------------------------------------------------------------ FINAL INSPECTION BY:- ----7X_ ----- --- Date----7-`----------^------------------ - -- - ------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Nazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street +. Stockton,California Lodi,California Manteca,California Tracy,California F.P.C q.