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FOR OFFICE USE: / C�ry } i �I- b=r' � 1 1. Permit No. __..-l.._1-7 r APPLICATION FOR SANITATION PERMIT ------ (Complete in Duplicate) Date Issued ___---- --------------------- This Permit Expires 1 Year From Date Issued l 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 wi County Ordinance No. 549. ------------------------------------------ ---------- JOB ADDRESS AN LOCATIO : ____ _ - r 1 j Phone----A/0 "�__`'-�? Owner's Na e -f /��j�l 'L`_S.�"_e ---- - ; J f .. = '�: , C_ _Q._ --------------------------------------------------- Address- - Contractor's Name---- r_ --- Phone..------•------------•--.... t Installation will serve: _Residence d Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ! --- Number of baths -_�--- Lot size _ n"- --�gb--•--------------"------ Numbar of living units: _�_:- Number.,of bedrooms _� Water Supply: Public system ❑ Community system ❑ Private© Depth to Water Table _/--_-_ ft- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam or Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date---___---_"_..__._) No R,� New Construction: Yes ❑ No Pfr FHA/VA: Yes ❑ No ❑' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) l p m nearest well-----------------Distance from foundation--------------------Material.__._____.___---_____________-_______--___.__. Se Tank: Distance from - Size--------------------------------Liquid depth-:----------------------- Capacity--------------------�- No. of com - ` D'_.-_.Distance to nearest lot l fe___�'�_---- ! Disposal Field: Distance from neare well-________________Distance from foundation__.- ___.. Q---------.Width of #Tench__ -- Number of lines_____ .______ Length of'each line__-__-____-'_ rP i . f - r� De th of filter material___� ___._____-Total length_-_ _____________________.___ � Type of filter*materia. .-�.-�•�--�-�-� p �, G Seepage Pit: Distance to nearest wel _.: - '_---________Distance from foundation------------------- Distance to nearest lot line----------------- + ❑ Number of pits. Lining material ------- Size: Diameter--- -------------------Depth--------------------------------- Cesspool: Distance-from nearest well-----------------Distance from foun ------------.----...Lining material---------------------------------- Size Diameter. Liquid-Capacity- -- -------- .----gals. Priv � - Distance from,neas.est well-_-.________.___ ______ ._ _____________________Distance from nearest building-------.__._.--_____.__---___.______----_. e Y ----------------- Distance to nearest:lot line ----- ------ --------- ----------- --------------------------------------------;-::;-_---------- - --------------- 1 ❑ a � Rgrnodelingand/or repa3rin� (describe X/.s5«----A--1---9--- 9 J. Q = - �CDD , -------------------------------- ------------------- ----------•---- ------------------------------------------ -------------------------------------------t------- -------- --- ------------ I her _ eby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, St a laws, @nd rules regulations of the San Joaquin Local Health District. � .. / r f - Owner andicrr-fes►t�ac 1 (Signed)(, BY� ------------------------------------ -------------------------------- - --(Title)-------------------:-- --------- ------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). a FOR DEPARTMENT USE ON Y i --- w f kN DATE_. ' �- -- -------�---- APPLICATION ACCEPTED BY�l-------. - REVIEWEDBY--------------------------------------------- -------------------------------------------------------------- --------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------ -----------------------------r------------- DATE.------------------------- ------------------- -------------- a Alterations and/or recommendations:------------------------------ - --------------------------------------•-------•--------------------= ------------------------------------------------------ ----------------------------------- ----------------•--------------------- ---------------------- -------------1l -------- ------------------------------------- ---------- - ----------------=---------------------------- ------------- --- ----------------------- ------ - - - ------------------" FINAL INSPECTION BY:-------- ------ ....._ ---- "`-f--------- Date_ C r i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124'Sycamore Street 205 West 9th Street 5tocklon;California Lodi,California Manteco,California Tracy,California ,