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F OFFICE USE: =p ------------- ------- ' -.-.--/fV. -+ � _�_=_______ __ Q 7i�-_. APPLICATION FOR SANITATION PERMIT Permit No. --------------------- -- (Complete to Duplicate) Date Issued -------------------- -no--.---.-------.-.-.--. 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. S49. JOBADDRESS AND LOCATION_____/---�--------- ------------------ ---------------------------=------------`--------------------------------------------------------------------------- Owner's Name----- ' - ----•- Phone-7-- -- ----- ------- - Address " ......---'- -- ----------------A...-----------------------------------"---"----------- Contractor's Name------- --- - -- ----------------- ----- -----. Phone %,.O' Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .-/--- Number.of bedrooms ,3- Number of baths 3--- Lot size -___- s -_ -. ----------------- i { Water Supply: Public system ❑ Community system ❑ Private [!r�epth to Water Table A.® ft. Character of soil to a depth of 3 feet: Sand ❑ , Gravel ❑ Sandy Loam ❑ Clay Loam p Clay ❑ f-Adobe jW Hardpan ❑ Previous Application Made: (If yes,dote=---..........-...--} iNo New Construction: Yes gi-ono ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: s (No septic tank or cesspool permitted if public sewer is available within 200 feet. a v Septic Tank: Distance from nearest{welld________Distance from foundation__�-Q--__--__.Materi#l_._ �--.-_._---- .--- [� No.. of compartments-----�.--------------Size-3_g.'- -�--------Liquid depth---------------- Capacity ® _____.Ca acit - Disposal Field: Distance from nearest well_!P ....Distance from foundati n-_2 0_..-..-.Distance to nearest lot line-4------------ Number ----.---_.Number of lines-----_--/---.--_--- ___- -Length of each line---� -�---------------Width of trench---_--_e -_ __--- ,,]] s ,f Type of filter mate rial!Al"o-C-,Depth of filter material---- .---.-----Total length---._--.-_-------------- 'd_------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to neares0ot line--.----,------.-- 0 Number of pits----------------------Lining material--------------------.._-Size: Diameter------------------_----Depth-----------------. : ----------- 6 r ,... � r Cesspool: Distance from nearest well-------------- --bistance from foundation---.-..---..--..... Linrng material-- . 3---- _ - ------- ❑" Size: Diameter--------------------------------------Depth ------- ::-:. =; Liquid Gapaci#Y — --� . -'.. gals. . Privy: Distance from nearest well-------------------------------------------------Distance from 'nearest building-------------------------------d___.-___-. ❑ Distance to nearest lot line-----------r------------ -------- ------------ -------------- -----------=---------------------------------------- ------------------ Remodeling and/or repairing (describe):---- - --- "--- ------- ------------ R ---.-L_-` _•. S - ------------ --------------------------------------------------- --------- --------74------- ------ ------ --- --------------------------•-------------------- -- ------- -- --- , ---- ------- ----- - -- --------------------------------------------------------------------------------------------------------------- I hereby certify that I,have prepared this application and that the work will be done in accordance with San Joaquin County f ordinances, State laws, and rules and regulations of the San Joaquin Local Health District, f n (Signed)--------- (14- --- ---- -- p _- - - ---------------------------------- ------ {Owner and/or Contractor) iBy:---- - ------------------------{Title)----- (Plot plan, showing size of lot, location of system in Tela n to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENTASN �^ i APPLICATION ACCEPTED BY- ---- ------- -- - ---- ---- ---- -� ,.,.- _�V-.pAT1=---------------------- --- --------------------------------- --� REVIEWEDBY---------------------------------------------- -------- 'f ===-------------- DATE----------------------------------------------------------- BUILDING -- � •' -- BUILDING PERMIT ISSUED " ----------------- --------- DATE Alterations and/or recommendations: e-ArG � _-. � ----- _. ---------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------'-------------------------.------------------------------------------- ---------- ---------------------------- ----------------------•--------------------------------------------------------------------------------------------- ------- ----------------------------------------------------------- ----- FINAL INSPECTION BY: r--__�z ---- ----------- Date--- �� T--. --'-------------- -----s----------- SAN JOA{, UIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.co. ,