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7 FOROFFICE USE: ! � APPLICATION FOR SANITATION PERMI ------------------------------------------------------- (Complete in Duplicate) ��i mit No. __ ._7 This Permit Ex fres i Year From Date Issued Application is hereby made to the San Joaquin,Lpcal Healfh District for a permit to construct Date issued -- This application is made in compliance with Count y Ordinance No. 549. uct and install the work herein described. JOB ADDRESS AND LOCATION Owner's Name__ ------------ ---------------;------- ? �'ti Address . ----•--- . _- yti L = y Phone.... 7-� _ ontractor's Name------ --------- Installation will serve: Residence ----------------------------------- ---------------------- Phone. ❑ Apartment House ❑ Commercial i Number of livingunits: - ❑ Trailer Court /(�. Mo+el ❑ Other ❑ /.�'~_ Number of bedrooms -- Water Supply: Public system ------ Number of baths -------- Lot size Y ❑ Community system ft. Private„ Depth to Water Table � ------•--•-------•-- Character of soil to a depth of 3 feet: Sand ��- ft. ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clayr Previous Application Made: (If yes,date----------------- ❑ Adobe,p Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ) No� New Construction: Yes V No ❑ ' FHA/VA:.Yes ❑ No„� (No septic tank or cesspool permitted if public sewer is available wi+hin 200 feet.) Septic Tank: l p Distance from nearest - efC----------------Distance from foundation----------------- ❑ No. of compartments---�----------------------Size---•--•---•- --.Material--------- -----°--------•---•----------�------•-� ; Dispo I-Field:" Distance from nearest we . ----- ----''-Liquid depth_---------------__---- capacity------------------- P ____________ __ .5=distance from foundation p Number of lines------------- ��-.�-'.Distance to nearest lot line_-___-5._ ' Length of each line---------------- Width of trench c� Type of filter material__ 4 -- -____.Depth of filter material _Totaf length ��--_- - -- --_-_-__----- See-page Pit: Distance to nearest well ' �j ij length from foundation la to nearest lot fine_-S+ I Number of pits._=i �_-_____-___L ing material._ Size: Diameter_ _ {� GDepth -�f7 ---- - Cesspool:. Distance from nearest well___________•----Distance from foundation-____-______. ❑ Size: Diameter----------------------- Lining material-------------eptly ---- •----- •---------- l Priv ------•--- ------Liquid Capacity-----------------•----------gals. ' Y� Distance from nearest well __-----_-.-_ Distance from nearest buildin ❑ Distance to nearest lot line------------- ---- - — 9 ' ----------------------- -----------------------------____ _ Remodeling and/ repairing (describe):__ _ - ----------••-- --•-----------------+------------------•----•----•--•-•-------•--•--•--•--------------------•-------------------------- ------- -----------`--------- - ----•----------•------•---•------•---•-----------------------••------^--------•--------•--------•--•---------•-------------------•----•---•---------------------------------------'- •.:d - 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)---------- - ----- - ---- Owne and/or Contractor) - ------------------------------------ ---•------ -- - ----- - -- --------------------------------------------- (Title)_- c Pot plan, showing size of lot, location bf system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY V APPLICATION ACCEPTED BY__Q__,__ ---------------------------------•-------------------------------• DATE----�--='--!� �=L---•---------•--------- REVIEWED BY----------------------------------- ---- ---- ------- ----------- ----------- ----------•- ------ DATE----- --•--------------- ' BUILDING PERMIT ISSUED ------•-------------••----------------------- ---------------------------------- DATE - -- - Alterations and/or recommen dafions:_;�-__'_2_ _-�--� �t� ----------- ------------ ------------------------------------------ ± --------------------------------- FINAL INSPECTION --------------- ------------ Date ---------------------------------------- 3 ' t SAN JOAQUIN.•LOCAL HEALTH DISTRICT 730 South American Stree} ' f 300 West Oak Street ♦ 124 sycamore Street 205 Wast 9th Street Stockton,Cpiifvrnia - Lodi,California Manteca,California Tracy,California X