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FOROFFICE USE: ------------------------------ -- ------_--fz/�64-..---- /4_-100-. APPLICATION FOR SANITATION PERMIT Permit No, _�_ __. . ---------------------------------------- ---------------- (Complete in Duplicated -- This permit Expires 1 Year From Date Issued Date Issued ./ �_ca�_-�S Application is hereby made to the San Joaquin Local He4th District for a permit to construct and install the work herein described. This application is made in compliance with County Ordi nje No. 549. JOB ADDRESS AND LOCA j�l_______ ______ ----- --- ......T_ -- I_-T-c -(_------------- C =•.. Owner's Name t Q -----•------ -A----------- ----------------- - - -------------------- ------------- Phone_5t"a? ------ q�� Address-----•-----------•-..- tr a� ¢� �//`` j/ Q© J Contractor's Name__ '--V- �.--}- --•------ ---------- - �l _�----------------------------- Phone_�'T p__`!3 4-_y1 Installation will serve: Residen4C --- ❑ Apar ment House ❑ Commercia ❑ Trailer Court ❑ Motel ❑ Other (� :•" Number of living units: Nu er of bedrooms _t3--___ Number of baths --- Lot size-r__ 1_, .__.__-______-_ Water Supply: Public system ommunity system ❑ Private ❑ Depth to Water Table _____ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ C3ay Loam ❑ Clay [] Adobe Hardpan ❑ Previous Application Made: {If yes,date......... ..........) No ❑ New Construction: Yes ❑ No i HA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: te - nk esspool permitted if public sewer is available within 200 feet.} Distance from nearest well-----------------Distance from foundation--------------------Material---------_-------------_--_____.___.____--___-. No. of compartments---------- --------- - ---Size_-------------------------------Liquid degtll-------------------------Capacity... ------------------ Distance from nearest well--Ar'!—)istance from foundation____ -------- Distance to nearest lot Ii Number of lines-____ ____ -- Leng}h of each line______. fl_'�______-Width of trench.-��Ke-lr _.__ Type of filter mater- Depth of filter material------/-P--------otal length-------------------- f�--------- D ----- �l1 Distance to neares well--N.�Distance from foundation------/tr- Di a f to nearest lot line----- N umber of pits.___----_-.___-___Lining material-�C�'-fo---u-ndation... _Size: Diameter__ ----------Depth___., Z��______________ \ `4 Cesspool: Distance from nearest Well-__ ______._-Distance fro _________________Lining material-_.--.____--______.____.--__-_______- ❑ Size: Diameter----------------- -- ---- - -- ---- -Depth----------------------------------------------------Liquid Capacity---------------------------gals. (� Privy: Distance from nearest well ___________________________________----------_-Distance from nearest building_---------__._____.__________-_..____.._ ❑ Distance to nearest lot line ------------------------------------------------ ! ------------------- Remodeling and/or repairing (describe): = --------------------- -------- ----------------------------------------------------- -—-- -------------------------------•-------------------------------------------------------- r - -- ----------------------•--------------------------------------- ------ -----•--------------------------------------------------------------------------------------------------------------------------------------- -------- ------------------------ -- ------------------------------- I hereby certify that--l�yy�,have prepared this'application and that the work will be do a in accordance wit San Joaquin County ordinances, State laws, apG aules and regulations of the San Joaq Local Health District. ed _ 2ag & Vi#kt Contractor (Sign By:—�B E-Miner Aua- rAN�_•..Hq 6- 1--------------------------------------- --- -- - - ----- --------Title------------------`- ------- -- ---- { (Plot plan, showing size of lot, location of system in relation to IIs, buildings, a ., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- ------- ------ - ------- -- ----------------•----------------------- DATE----------- - -- --- - REVIEWEDBY--------------------------------------------- ----------------------- - DATE--------------------------------------- ------------ BUILDING -- ----- BUILDING PERMIT ISSUED--------------------------------------- r E------------------------------------------------------------ -- ------ Alterations and/or recommendations:---__ _ _/ -- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------•------------------------- ------------------------- ------------------------------------ --------------------•---•--------- ---- ---------------------------------------------------------------------------------------------------------- ------------------------- --------. o FINAL INSPECTION BY:..... __._...._` �� 1� Date--------------- --- --- SAN JOAQUIN LOCAL HEALTH DISTRICT 1641 E.Haze-ton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.RCa.