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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) / Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This applicatiori is made in compliance with County Ordinance No. 549. t ' 1 ! �Q� t JOB ADDRESS AND LOCATIION_____17 I-------�y-------- r�------ ��---------------------------------------------------------------------------- Owner's Name----_4__.-Q--'----•-^L- K_i.&_ ojz�---------- ----- - Phone----------------------t------------ - ----------------=---------------------------------------- - Address------------- -�=�-------��.�:� ��.-----/---- ---------- ----------------------------- ------------- -------------- Contractor's Name---------------------6AM�-=-------------------------------- ------------- Phone------------------------ ------------------------------------------------------- -------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other - 4 Number of living units: _ Number of bedrooms -02—Number of baths Lot size ----- ------------------------- JQ t Water Supply: Public system �ommunity system ElPPrivateE] Depth to Wafer Table ----_- - f . Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [] Clay ❑ Adobe E( Hardpan ❑ Previous Application Made: Yes ❑ No E0 New Construction: Yes e No ❑ FHA/VA: Yes ❑ No {� TYPE OF INSTALLATION AND SPECIFICATIONS: i ' (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Se ptj ank: Distance from nearest well_ML—Distance from foundation----fV---------.Material---_FD.4 ----------- -- No. of compartments--------�------ ----Size=--------------------------=---Liquid defth--------------- -----=----Capacity------Z--D� os Distance nearest ---- Dis ,Field: Dift weIIJJO E1 -Disfance from foundation-1.0- Distance to nearest lot line'__------ _ Number of lines- �. ------ ----Length of each line----0 --1°'r10-.Width oftrench---------3.6--j-r---------------- Type of filter material ----;?&.K�----Depth of filter material---_--, ____--.__Total length----------110-_----Fa -- Seepage Pit: Distance to nearest well-------------ii*-----Distance from foundation....................Distance to nearest lot line--_------_---_--_ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----------------'-----.Depth--------------------------------- v Cesspool: Distance from nearest well----------------Distance from foundation---------------.----.Lining material--------------_______-_______-__-__--. � ❑ Size: Diameter.--•'-------------------- ----------Depth-----------------------------=------ :--------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building__;__.___-_-------_-----__-_----_____ # ❑ Distance to nearest lot line--------------------------------------------------------------------------••-------- ---------------------------------------------- i Remodeling and/or repairing (describe):---------------------------------------------------------------------------------------------------- --------------•----------- -----------------------------------•-•--=---••---------------------------------•--- -••---•------ I hereby certify that I have prepared this application and that the work will be done in accordance with San'J6aquin County ordinances, St to laws&,ancdf-r lesand regulations of the San Joaquin Local Health District. � I (Signed)-- _ '-------------------------- ------------- ------------ ------- - ------------------------------------------------------------------ -----(Owner and/or Contractor) , By:-----------------------------------------------------------------------------------------------------------------------------------(Title)---------------------------------------------------------------- (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side).' r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- 7 s_R rO'------=------------------------ ---------------------------------------- DATE----------j7 7 ------------------------ REVIEWED ---------------------REVIEWED BY ----=----------•------------------- --------------------------------------------------------------- DATE--------------------------- ----- ------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------=------------- -------------- Alterations and/or recommendations----------------------------------------- ----------------------------•--------- . --•--•----- -•-----•--------------- -----------------••-------- I ----------------------------- 1 -------- -------3-6----- ----4�_:-A-_a4--------a K--- -------------------------------------------------------------=-------------------- -----•--------------------------------�AW�---------0-A--•-------- ---------------------------------------------------------------------------------------------------------- ---- -- ----------•- -------r-=------------------ FINAL iNSPECTI e BY:. - - — J Date : �/ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M . Revisea 1.57 F.P.CO. a