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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. QZE ----- - ---------------------- --------------------- -- {Complete in Duplicate} J'� .3--G� This Perm it Expires 1 Year From Date Issued E� Date Issued .fir_____----------- ------------------------ ______ _ O!p(.--t�sed•-r�� Application is hereby made to the San Joaquin LI al Health District for a permit to construct and instali the worVneiz,„ldescribed, This application is made compliance with County Ordinance No. 549. _in_ !BB - JOB ADDRESS AND LOCATION__�-��--g -�'`':��--- �----�--�- --- ---- 'I! -----� ------. Phone------------------------------------ t Owner's Name--- - - - ?-==�'-----='------ '� - - -------- r)----- Address - ------_ ----- - -- --------------- > -,. A - - Contractor's Name------ - - ---------- - -- ---•ii---------- ---------- -------- . .. _. Phone.. Installation will serve: Residence ❑ Apartmenti House ❑ Commercial Trai_lerr Court ❑ Motel ❑ Other ❑ r Number of living units: Number of bed rooms�.-,Number o baths --t-- Lot size ------------------------------------------------------------ Water Supply: Public system ❑ Community syp tem ❑ Private Depth Water Table -------- ft. Y Character of soil to a depth of 3 feet: Sand Gravel Send Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ C p y ❑ Y Previous Application Made: ,[if yes,date.___-- - -_::_) No ❑ 1New 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.) - 'M - ” "C k< Septic Tank: Distance from nearest well---- -----------Distance from foundation--------------------Materiai------------------------------------------------- El -�h No, of compartments------------ __.______ . Size--------------------------------Liquid depth----------- ---- ---- ----Capacity...--- ------------- m r 1q......___.Distance to nearest lot line.... Dis ase field: Distance from nearest well_��_____ _._Distance from foundation i Number of lines---------- __ IM Length of each line------ 5:-- -�-._-_____Width of trench________________________._____._ -e- Type of filter material-_--A P., '___.---Depth of filter material-----�-------------Total length--____-- _.__--_ ------------------_--- Seepage Pit: Distance to nearest well ___.__---Distance from foundation------------------- Distance to nearest lot line--_----------_._ . ❑ Number of pits----------------------d1ning material-----------------------Size: Diameter- ---------------------Depth--------------------------------- Cesspool: Distance from nearest well...Ihi�-_-_---_._-Distance from foundation--------------------Lining mateeial_..._ _-___-______---- ❑ Size: Diameter------------------ -----1f---------- Depth- ----------------------------------- - .-;--------Liquid Capacity----------------------------gals. Privy: Distance from nearest well_ ___________________ ________________Distance from nearest building----------------------------------- Distance to nearest lot line.-.9---- ----------------------------------- ----------------------`-=-------------- I Remodeling and/or repairing {describe:__._________________ __ i ;I y 1! --------------------------------------'---------- -:------------------------------------------------------------- ---------- M ----------------------------------------------------------------------------------------------------------------------------------------------{---------------------------------------------- -------------------- - I hereby certify that I have prepared this application and that the work will be.done in accordance with San Joaquin County ' ordinances, Stat aws, and rules and regulation of the San Joaquin Local Health Districf. E - 5i ned - -=------ ------------- ----------------------------------- -------------------------- er and/or Contractor) q . ..,a. By:.` - — ----= -- _ Title ---_--------�;L_----.-..,,..... (Plot plan, showing size of lot, location of syste lin relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- ----------------------------------------------- DATE--l-1. 3 ------------------------------. REVIEWEDBY-------------------------------- ------------------ ---- b------=--------- ---------------------------- ------------------ DATE-- --- --------------------------------------------------- BUILDINGPERMIT ISSUED----------------------------------- h---------------------------------------------------------------- DATE--------- -------=------------------------- --------------- i Alterationsand/or recommendations: ----- --------------------------------------------------`---••-----•------------------- ------------------------------------ -------------------------------___-------------------------------- ----- �P------------------------- ------------------------............--------------------------------------- ..-------------------'-------__---------------------------_---------------i--•------------------------------------_- _ ___________________ ----------------------------------------------------------------------------------------------------------------- ----------- -------.__-------------------------------------'-----.- ---.....-- ---------------------------------.------------------ FINAL INSPECTION BY:.._.-. �� - xv �� ,._.. Date-- - ---- ----------------------------------- +__e. , SAN �JOAQUIN LOCAL HEALTH.,DISTRICT 1601 E.Hazallon Ave. 300 Was Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California ,; Lodi,California Manteca,California Tracy,California F.p.ca. l i r