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FOR OFFICE USE: . ---------------------- APPLICATION FOR SANITATION PERMIT Permit No. .��1�12� - --------- ------------------ ---------------- --------- I (Complete in Duplicate) This Permit Expires 1 Year From Date Issued Date Issued ' - Application i hereby made to th an Joaquin tical Healfh District for a permit to construct and install the work herein described. i This ap icat o is adeoi �6&� ;th rdinance o. 549. /f/ 7 iY n� C/N�6�/ A2D a eTi/S T err�jss JOB AD ESS AND LOC ATION-- L ' Owner's Name 4= e- ,..... r --------------- ------------------------------------ ------.-- Phone------------•--------- Address------•---------`'3�° ?L• `��° � �`—�` ------ - ---------------------------------------------------------- - -- Contractor's Name --- --•------- .-•------------ ------ Phone----•---•-----------•-------------- Installation will serve: Residence [)4 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ { Number of living units: ---/--- Number of bedrooms .3_ Number of baths -147n- Lot size __--________ Water Supply: Public system ❑ Community system ❑ Private K Depth to Water Table Sa_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe X Hardpan ❑ Previous Application Made: (If yes,date--------- ..........) No . New Construction: Yes No ❑ FHA/VA: Yes ❑ No,P' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_-_tSD' Distance from foundation______ __________________________�_ !4F; _ JCy No. of compartments------------ --------Size__ 1«`1+C .__...:...Liquid depth----.-�---------------Capacity---XRO-A Disposal Field: Distance from nearest well---S�--r--}_Distance from foundation-----_Q..........Distance to nearest lot line----S_�_____ a\ Number of lines-!_-----I'--------------------Length of each line-----------Z�__!---------Width of trench--------- Type of filter materia!_$%A C!C___.Depth of filter material------!4".___-Total length___________________ 3_"O- `a -------•. --- 5eepage Pit: Distance to nearest well----/4Q-�-____.Distance from foundation__-,7 ----•._.Distance to nearest lot line____J�_�_. Number of pits-_ -------Lining material- ,-_��_-Size: Diameter__-_=_3 _''__-_.Depth_____-_.______.�J�` Cesspool- Distance from nearest well_________________Distance from foundation----------------- Lining material-_.___________.______._ I ❑ Size: Diameter.. 1--------------------------------Depth----------------------------------- --- - - ------Liquid Capacity--- ------------------------gals. Privy: Distance from n iarest well_____________________________ _ _ _._---_-______Distance from nearest building______________________________ I ❑ Distance to nearest lot line----------------- Remodeling and/or repairing {describe):------._.... � t�- c�^ - --------- ------------------- -------- ------ ------------------ -------------___ ��---' '----____- _________.l�S�.-r<�G-3.�'-�+G^"L_r-____.__ ________________ ___--_! L•+��i'v -__- ---LAG ______ _� ' y___________________________________________________________--------------------------------------- - --------------------- e `` r -------------------------- --------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)----------- �__ _ I - -------- -------------------------------- _ ------------( caner and/or Contractor) S. BY •--------- -------- --- - (Title) (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). [ � t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --��'�--- la'ti'' ---- ---- ---- DATE------------------------------- REVIEWEDBY- _----� ---------------------- ------------------- -------------------------------------- DATE BUILDING PERMIT ISSUED-------------------------------------------------- ----- - _.._ ... �v� --- DATE--------------------------- Alterations -------_---i---s----�---.---�----�- Alterations and or recommencations:__-__. " � _______________ .f__--_ G�._i _____________________________________ ________________ _______________________ --------------------------------------_-------_---------- ____ e _______-------------------_---------------------________________ ,r 1 FINAL INSPECTION BY ----------------- Date--------•' '` .-la.Cr _4 o- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazetton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California i - P.P.r O. i i