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FOR OFFICE USE: - -- ------------------------------- ------------- APPLICATION FOR SANITATION PERMIT Permit No. ..�. �1_.... - -- ------------------------------- --- - ------------- (Complete in Duplicate) Date Issued --- ---------------------------------_____ _______________ 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. I This application is made in compliance with County Ordinance No. S49. JOB ADDRESS AND LOC ATI N.. �� * --- J' /Y- / 'Q ---------------- Owner's Name ;T1, . /.l11ZAW4- t-f PhoneZZ.7 Address---------------------------- .4-57--------=5',__;1-�Y.---- Contractor's Name -------------------------------------------- ---------------- Phone-5Z_ ._ Installation will serve: Residence [P�Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/___ Number of bedrooms __�2- Number of baths /__-_ Lot size ____9(p__ ---Aw��------------------------- Water Supply: Public system 21'* Community system ❑ Private ❑ Depth to Water Table -------- 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 ❑ FHA/VA: Yes ❑ No ❑ 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 compartmenls--------------------------Size--------------------------------Liquid depth--------- --- - - ------ Capacity..--------------------- Disposa Field: Distance from nearest well - '__Distance from foundation___...2_5___J__.Distance to nearest lot line,_r2 ..... W Number of lines________f___ __�-- -----------Length of each line____rtf-�`7 j-------Width of french.___rx"�_ ---- --�s_.__ Type of filter material._.'/ D % ._Depth of filter material____ _________._Total length------- _ /// __.Distance to nearest lot line___ _______ ____ Seepag Pit: Distance to nearest wall_______—'-._.___Distance fro foundation______ _. LA Number of pits....... ...........Lining material_- ' ►'.Size: Diameter__TS-----------Depth_ —� Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material ________..___.______. 5 ❑ Size: Diameter------ -------------------------------Depth----------------- ------------ ---------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-----------------_----------------------------___Distance from nearest building____.---_----------__-_______...___.._... Distanceto nearest lot line----- --- ----- - ----------------- ----•-----------------...---------------------------------------------------------- �- - --._ p Remodeling and/or repairing (describe)____ �PV------- : '/. !//►/-�� •'/��/ �.1'�1------------------ I a f ------------------------------------------------------------------------------------------------------ --------------------------------------------------------------- ---------------------------------------- ------------------------------------------------------------------------------------------------------------ ------------------------ --------------------------- -------- I --- --I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) �G �!.1 �f wn ntl/or Contractor By:--- --- - -------------------------------------------(Ti+le} - -------------------------- (Plot _—.__. ------------- (Plot plan, showing size of lot, location o system in relation to wells, buildings, a+c., can be placed on reverse side}. i= R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- ----- -------- ------ ---------------------- DATE------ - REVIEWEDBY-------------------------------------- ----- -------------------------------- ---------------------------------------------- DATE------------------------------------------------------ BUILDINGPERMIT ISSUED---------------------- • - --- - ----- -------------------------------------------------------- DATE.- -------------------------------7---_-------------------- i Alterations and/or recommendations:----- - -- -----------------------------•-----------------------•-•---------- -- -------------------------------------------- :_ _ -tea= ------ ��- ------------------------------------------------- - ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------- _�2� G FINAL INSPECTION BY:.f/✓✓� . ___-- / Date.... _._ . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CM