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FOROFFICE USE: - "' ...�...,,. . ------------------- ---------- P ' --------- _---_---.._-.-__.-__"-______ APPLICATION FOR SANITATION PERMIT Permit No- ;�_J ------------- ------------------------------- (Complete in Duplicate) -44- ---------- --------------- This Permit Expires i Year From Date Issued Date Issuedw --•--- F 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 incompliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION:,----- w(------- _1r�_i►- = ------------------------------------------------------ Owner's Name--------------- 21711]£1 :------p3g1-ti{----------•----------------------------------- --------- Phone Address-------------- -�5 ,5-jEeSi�- I P! - = Phone Contractors Name------------ ------------- -�----------• ------•-- Installation will serve: Residence!�Apartmenf House 0 Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___/ Number of bedrooms 4 ' Number of baths ----!-- Lot size ------ ---------------- E Water SuPPIY� � Publicsystem Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 fest: Sand ❑ Gravel ❑ Sandy Loam [❑ Clay Loam ❑ Clay ❑ Adobe [-Hardpan ❑ { Previous Application Made- (If yes,date---------------- ---) No 2 New Construction: Yes Le—No ❑ FHA/VA: Yes ❑ No R4-1` 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-A&A..---Distance from foundation----Iqj_.__.. Material--__.eQ71G _----_ Fkr r Size BO > =; No_ of compartments °� 3.- "-----------------Liquid depth------�� ----- Capacity----- Distance from foundation___ .._---.---Distance to nearest lot line__- Disposal Fie3d: Distance from nearest wel!_�Oy�-.- Ell" Number,of lines-'------------I ------------------Length of each line-----.----'f V- ------.Width of trench---------,9 r-----.-'-'- -----= Type of.filter material__3•-__ _ -__----__Depth of filter material----/V-__------_._Total length__._----__12Q/------------ I Seepage Pit: Distance to nearest well_PPNX._______Distance from foundation____ o---------. 9-_ Distance to nearest lot line__.-4�!____•• f � W_ Number of pits._.----_ ____________Lining material----'R----_____Size: Diameter"____..3 ti Depth &W .- Cesspool: Distance from nearest well-----------------Distance from foundation--------------.____.Lining material--__ -_____-..__--_.___. ❑ Size: Diameter----i---------------------- ---- ----Depth-------------------------- ----------- ------Liquid Capacity-------------------------------- ------ ---------------------Is. .� Privy: Distance from nearest well....--____--__--------------------------------"Distance from nearest building ❑ Distance to nearest lot line------------------------- Remodeling and/or repairing (describe):----____..___- - - ------�-�- - �-�-----•------•-------------------------------- I --------•------------------------ -------------------------- --------------------------------------------- ----- ; ----------------- ------------------------------------ I hereby certify that 1 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. ____ .__-_ - I (Signed) / --_ '' - � `" -__.._._-_(Owner and/or Contractor) -------------------------------------------------- BY•--•----- - -- --------- ----- Title ---------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). y N. t # FOR DEPARTMENT USE ONLY r APPLICATION ACCEPTED BY _ ------------------------------------------------------ EV W DATE_____-- _- __6�,_ i ------------- REVIEWED BY--- -- ------ ---- ---------------- ------------------------------------------------------------ DATE BUILDING PERMIT ISSUED----------------- ------------------- - DATE_---c °. ' Alterations and/or recommendations: - tt --------------- --------------- - ----- --- eNr Il.w_trRe.r., �t ..� l FINAL INSPECTION BY--------------------I------------- ------ Date----------- --------- SAN -SAN JOAQUIN LOCAL HEALTH DISTRICT II 5 1601 E.kaselton Ave, 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California + F.P.C Q. h '