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FORE OFFICE USE: ------- APPLICATION FOR SANITATION PERMIT Permit No. ._.�91. .. ------------------------------------------ r --------------------------- --- -------------------------- (Complete in Duplicate) --------------- - -__ This Permit Expires 1 Year From Date Issued 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. 549. /�- � - JOB ADDRESS AND LOCATION------ -- / ----------- ------------------- - ------------------- - Owner's Name------------/�-•--------------- ✓ ------- -- Phone Address-------- --- ! �a' _�� 1� ---- ----------- Contractor's Name--- 'P--------•------------------------------------------------------------------------------------------------------------ Phone---------------------_------------ Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [] Other ❑ Number of living units: �_ Number of bedrooms __2- Number of baths -2-- Lot size _____________ - ---=-`•? -� a Water Supply: Public system El Community system El Private Ej�epth to Water Table Gd—ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe ❑ Hardpan Previous Application Made: (If yes,date.................. .) No ❑ New Construction: YesNo ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: i (No septic tank or cesspool permitted if public sewer wer is available within 200 feet.) 1 Septic TT nk: Distance from nearest well-----r---0__ .Distance from founda�on----1_U-------Material--r___________________________________._____-. LJ No. of compartments ---------Size �X � x Liquid r�Rjh ------- Capt cot Ij t , Disposal Fuld: Distance from nearest well.- Distance from foundation---1�_._`____...Distance to nearest Number of lines___________. ______________ Length of each line_____._ Cl.__ -_-_-Width of trench------ ._ ___...__._._______ Type of filter material___-R_.d_ -Depth of filter material-------�__�-'._1.�----Total length-._ _ - ------- -- Seepage Pit: Distance to nearest Well-------------__------Distance from foundation--------------------Distance to nearest lot line..________ ❑ Number of pits----- ------Lining material-----------------------Size: Diameter----------------__.----Depth------------------_------ --- l6ti # 4 — Cesspool: Distance from nearest well----------------:Distance from foundation------------.______.Lining material_3_...____--_---- _--__-___-______ ❑ Size: Diameter-- ----------------------------------Depth--------------.-----------------------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well------------- ._Distance from nearest building ❑ D.istance to nearest lot line------------------------- ---------- -------------••----------------------------------------- -------------------•---------------------- Remodeling and/or repairing {describe}---------- --- -----------------------------------------------------------------------------•-•------------------------------------------------------- ----------------------------------------------------------------------------------------------- ----------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State lalaws and rules and regulations of the San Joaquin Local Health District. ` �" c C�i- - --------------=;,--- ------------------ -------------------------- Owner and or Contractor (Signed);��--- { � I 4 By:---------------•-------------------------------- ------ --------------------------------------------- -------------•-----------(Title)---------------------------- ---- .--- - -- - -- ----- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.- _,��-------------------------- ----- DATE---------- - ' (` REVIEWEDBY------------------------------------------------------------ ---- ---- ------------------------------------------------------ DATE------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------ ----------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations--------------------- ------------------------------------------------------------------------------------------•-------------•---- -------------------------- --------------------- -------------------------------------•-•----------------------- ----- --------------------------------------------------------------------------------------------------------------------------------- •-•-------------------------•---------------------- -•- ------ --------------------------------------------------------•--•---------------------------------------------------------- ------------------------------------ ------------------------------ --- , ---- ' � FINAL INSPECTION $Y:. rJOAQUIN Date I / --•------ x ------------•--- SA ---- LOCAL HEALTH DISTRICT , 1401 E.Ftaielton Ave. '300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California i ' r.a.co. { 1