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FOROFFIC-E USE: ----------------- ------------- ----------------- APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) This Permit Ex fres 1 Year From Date Issued bate Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herem3descrbe-IDd. This application is made in co pliance witCou ty Ordinance No. 549. ` g:t �.. .:. c q 1_0 IV---- JOB ADDRESS AND OCATI N__1_Q -___.� _ .___.__- � ___ �-�-' Owner's Name---------------� l C;_RA��-----------------� -�-.-�--�.�- ----------- Phone---------------------------•-------- ---------------------------------- Address-------- �__.- 1,3D�C /4�Q �S I)� Contractor's Name _77I R...... ------ -------------- ---- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ 6fher ❑ Number of living units: _ _.____ Number of bedrooms _��_____ Number of baths --'—'—Lot size ___19—C1��_�`r�=----- rr -------------------- Water Supply: Public system ❑ Community system ❑ Private 0 Depth to Water Table3�. d Character of soil to a depth of 3 feet: Sand �Oravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--- ----------------) No ❑ New Construction: Yes FHA/VA: Yes ❑—No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Q Septic Tank: Distance from nearest well---s_D----Distance from foundation__/_v----------Material_ _1._ :-----------. {� No. of compartments___--____3-_------.--Size__60...X_'?_________.__ Liquid depth__-_YA_- -Capacity...,QZ Disposal Field: Distance from nearest we31..-50-----Distance from foundation---/v-------- Distance to nearest lot ❑� Number of lines--------1-------------------------Length of each line_..__!/ _`'��_-Width of trench------�?'f_rf_---.-_.__-___. O Type of filter material__ V_CY----_--Depth of filter material____/ ............Total length----------------/,:�n___'._________ I Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- El dumber of pits----------------------Lining material---------- ----------- Size: Diameter.--------------.-------Depth--------------------------------- Cesspool: Distance from nearest well-------------- from foundation--------------------Lining material._._____-_______.__.__._______-______- ❑ Size: .Diameter-------------------------------------D Pfh--------------------------------------------- ------Liquid Capacity----------------------------gals. Privy: Distance from nearest well_________________________ -__-_Distance from nearest building----------.__.._____._________.__..____._. ❑ Distance fo nearest lot line------------------ --------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe)---------------------------------------------------------------------------------------------------------------------------------------------------------- I; -----------------------------------------------------------------------------•------------------------------------------------------------------------------------------------------------------------------ - -- --------------=---- -----------------------------------------------------------------------------------------------------------------------------------•--------- -------------------------------------------------- C ---------- -- ------ - ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- C �� I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County rn ordinances, State laws, and rules "d"regulations of the an Joaquin Local Health District. " (Signed}_______________ ___ _ ___/_/ [� �___ _--y- _. .--__----_..-(Owner and/or Contractor) . By:----------------------------------------------------------------------------------•----------------------------�---------_----- (Title) - - - - - -------- ....................--_---------= . (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- s----- -- ------------------------------------------------------- DATE------lz7--3�:-.6Z-------- ----------------- REVIEWEDBY--------------------------------------------- -------------------------------------------------------------------------------- DATE----------------------- --•-------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------- Alterations and/or recommendations:_----- ----------- ---- ---- ------------------------------------------•-----•-•------------------------------------------------ ----- --------------------------------------------------------------------------------------- ----------------------- --------------------- ---- ------------------ ----------- - ---------- --------------- -------- --------- --------------- --- --- --- - - 1 ----A' _____________________________________ ______ r-------------------- ------------ ---- --------- - ----- ------- -. ............ 1 ------------------ ------------ FINAL INSPECTION-$Y•- = •-- Date.......1 l-----Q- -DC7- - ------------------------- SAN JOAQUIN.LOCAL HEALTH DISTRICT 1401 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street t Stockton,California Lodi California Manteca,California Tracy,California r•.P.C O.