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FOR OFFICE USE: APPLICATION F6R SANITATION PERMITPermit Na. - _`3. W -- + --------------- ------------------ -- --------------- � r ----------- --- --------- ----- -- --------- (Complete-in Duplicate) Date issued -- ----'C2_ _ -------------------- -------------------------------- 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. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION,_ r;!+" ��:r'k'�---.------P__. U� � �l�`�="=--------------------------------------------- Owner's Name------------�k--�--'-------- -- - - - --•-------------- --------------------- - -------------- --------- Phone------------•-----------------•----- Address----------••---7-1-s�---"-------...6 ---/ �r� --•--- ti Contractor's -----_-------------• --•-------------------------------- ----- ----------------------------------------------- Phone------ ---------------------------- Installation will serve: Residence ,V Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ -- I Number of living units: _f----- Number of bedrooms _. .- Number of baths.I---- Lot size _...�0_t_/.44-----------------------------' ' Water Supply: Public system ❑ Community system 0 Private f Depth to Water Table AP_ ft Character of soil to a depth of 3 feet- Sand [jGravel ❑ Sandy Loam I} Ciay Loam [] Clay E] Adobe [3Hardpan [ - 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.) T , Septic Tank:. Distance from nearest well-----------------Distance from foundation------------------- Material ------------_----.------------------ ------ . ❑ No. of compartments---------------- ...Size-------------:--- -- - ---------Liquid depth--------- ------- --------Capacity---------------------- I Disposal Field: Distance from nearest well__.............Distance from foundation--------------------Distance to nearest lot line------.-.-._....- ❑ Number of lines----------------------------------Length of each line-----------------------------Width of trench.---------------------------------- Type of filter material-------------------------Depth of filter material...-----.--------------Total length---.---.---------------------------------- g��t: Distance to nearest well_.S'd------------Distance from found ation_--Q----------.Distance to nearest lot line___.______ ❑ Number of pits--- .---------------Lining material__...... Size: Diameter... 'r.1. Depth....J_ Cesspool: Distance from nearest we0 ------.-..__--Distance from foundation----------------- --Lining material-----------------------_-------.------ ❑ Size: Diameter- -- --------- ----- --------- --- -Depth--------------=----------- - - - - -- --------------Liquid Capacity- - ------------------------gals. { Privy: Distance from nearest well--------------------------------------...___._..Distance from nearest building---------------------------------- ....... . ❑ Distance to nearest lof line ------- -------------- - ------------------------------------------------------------------------------------- ---- 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 Joaquin Court ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)------------ _�?-=----- ------ ' ' -----./ '�' ase '------ --- -------------- ---- _________________...__..__.._...__(Owner and/or Contractor) 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 rr�� APPLICATION ACCEPTED BY -- ----------------------- -------------- DATE-- .2 G f -------------------------- REVIEWED BY-------------------------------------------- - ----------------------- -------- ------------ ---------------- ------ DATE---------------- ----------- -- - -------------------- - BUILDINGPERMIT ISSUED-------- ----------------------- - ------- ------------------•---------------- ---- ---------------.- DATE---------------------------------- ------------------------ Alterationsand/or recommendations----- -- ------------------------------- - ---- -------------------------------------------•- -------- --------------------------------- ------------------ -------------- -------------------------------- ------------ - - --------------------------------- ----------------. -------------------------- --------- . ..--- -- - - -- ------------- } ------------------ ------- -----------.-------._-- ---------------- -- ------------------- ---- - ------------------------------------------- -• .. ------------------------------------------ { a FINAL INSPECTION BY:.. ----- Date_... - ------- ------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi, California - v Manteca,California Tracy,California E.H.9 2M 1.67 Vanguard Press