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UKOFFICE USE: - -------------- -' . ' Mow APPLICATION FOR SANITATION PERMIT Permit No. `______.._- - -- - -- - I - --- (Complete in D,tplicate) ..� "- -"" -- --- "" "" ----- ----------------- - This Permit Fx fires 7 Year From Date Issued - .._ Date issued ___ Application is hereby made to the San Joaquin Local Health District for a permit to construct and instal! the work herein described. This application is made in compliance with County Ordinance No. 549. OB ADbRESS AND OCATION___"__ �. Owner's Name___________ __ �� 2 rl --------- . 1� k 33;0 - - Phone Address --- ---"-• .---•- ----- -•--- ff " 1 N . .� ----------.-•-- -- Contractor's Name.____.__.___"___ --- "+' hone&� - Installation will serve: Residence - ""--"-"-•""---""--""--""---""-""""" ----- ---- --------------- I -- �.. ❑ Apartment House ❑ Commercial ❑ Trailer Court r �" ❑ Motel ❑ Other; Number of living units: -___-___ Number of bedrooms -------- Number of baths Water SuPPIY� Publicsystem ❑ -------- Lot size .__ �- -------nnY s stem Private `- to Water Table _1__,ff. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ ClayLoam Cla I db Hardpan ❑'t Previous Application Made:: (If yes,dpte----------- ___-"-"_) No New Construction: Yes ❑No Y ❑ Ac� I I .��• , ,TYPE OF INSTALLATION AND SPECIFICATIONS: ❑"'FHA/1yAI Yest❑ No ❑ (No septic tank or cesspool permitted if public sewer is available within 200 feet.) } �� � .. 9 Septic Tank: Distance from nearest well_-S®._�---__Distan Distance from foundation__3_� No. of compartments---v2---- 3K Material_ L ,,--__---- ---------- --- -- -- ------------- -------------Size------ S�x�----------Liquid depth -- e„,a z ` q p . _`'Ca acct g___ Disposal Field: Distance from nearest well-6.0-----._Distance from foundation. r 9 p Y Jd--""--."._.Distance t41 nearest :% Number of lines:_'.__ ___-_".__"- w Length of each-line__"_ �--------- �_""_ Type of filter materia! �_ -_ - -- -"- Width of trench___ ,M " -- 0..__ Depth of filter material".__�9_��.__""..Total length---._____�'�_ ____l_�_ __`__'_______ Seepage Pit: Distance to nearest well ______________ _Distance from foundation_"___"__ ___Distance to nearest lot fine-.-4___-____-_ ❑ Number of pits.j --- material-------------- -------- Size: Diameter_- ---------------"--Depth'._ _ - -- Cesspool: Distance from nearest weil-----------------Distance from foundation-______--_.-----..Linin material------- . - ❑ Size; Diameter.-_"._. ' � --------- --------- --- Depth----- -- --- --- -- _ i .g � �------ -------- - - ----Liq Liquid Capacity- gals. Privy: Distance from nearest well---- "---____ "._ - 0i ------_-___-.-_-_Distance from nearest buildin ❑ Distance to nearest lot line----------------------- g ------------------------ ------ 1 ' Remodeling and/or repairing{describ — r r - --------- .t- -------------- --- ------ - --------------------- ------------------------ - ----------- ------------------------------ ----------- "l�h'ave prepared I hereby certify that red this application and'that the work will be done in accoryknce with San Joaquin Count ordinance&5a41a , andjr les a dregulations oft a San Joaquin Local Health District. (Signed)--------•----- = _ ---------------------- ------------------ (Owner BY ----------------- -------------------------------- —L-- Owner and/or Contractor] ---------------- ------(Title)- ' r--------- ------ ----------------- (Plot plan, showing size of to#,.location of. system in relatio o wells, buildings, etc., can be place = reverse side). Ft FOR DEPARTMENT USE ONLY , APPLICATION ACCEPTED t ---.-.T -- -- :-- REVIEWED BY --------- ------ ------------------------- - ; -- - -=--- ----�'-�-� �------- -------- ------ ----------- DATA= BUILDING PERMIT ISSUED;.--I --------- ---------- ------------ --- �* ------------------------------------ ------------------------ : ,�, DATE ':-------- Alterations and/or recommendations - .y------Ct9�c�e�, -- - ---- ---------------------------- ---------- ----- ---. ----- -------- ." � ---n t` ,�� a f I a - ``` --� ------ ----- - --------------- I It ------'----------------------------- ------------------------------------ r = ------- ------- -------------------------------------------------------- ----- -='--------- --------- -------------------------- I--- ------------------ ----------- .- f -------------- -------------------------------------- ,w: ---------------- $ -- --�o- FINAL INSPECTION BY:__:`�e. � Date------ ---------------------'/_ SAN JOAQUIN LOCAL HEALTH-DISTRICT 1 1601 E.Hazelton Ave, {300 West Oak Street -+,.__ ,�. .124 Syaarhore Street Stockton,California ' �` 20S West 9th Street Lodi,California' ` 'Manteca,California �r�' 4 :"' 1 Tracy,California '"�+w