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FOR OFFICE USE: --------------------------------------------------- APPLlCAT10N FOR SANITATION PERMIT Permit No. ...f�Q�-�----- -----------------------------------------------------•--- yl ------------------------------------------ (Complete in Duplicate) Date Issued - --_.y_-.--. 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 + -------•----- JOB ADDRESS AND LOC I ---------- Owner's Name-------- , Phone._.. Address r 4 ----------•----------------------------------------------------------------•-•---------------------------•-------------.............. ----- Contractor's Name.............. Phone.............~.__..------•---..,-- -•-------.---- Installation will serve: :Residence Apartment House❑ Commercial [I Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ..-: Number of bedrooms �. Number of baths . -. Lot size r-- --®----- k--•-------•-----•-- Water Supply: Public lsystem Community system ❑ Private ❑ Depth to:Water Table ' �}}. T Character of soil to a depth of 3 feet: .Sand ElGravel ❑ Sandy Loam El clay Loam ElClay L] Adobe Hardpan ❑ Previous Application Made: (If yes,date____________________) No New Construction: Yes ❑ No Z?,"FHA/VA: Yes _ No g;.— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se tic Tank:, Distance from nearest well-------------------- ` ---------------------------Distance4 from foundation_________________Material--------------------------- ----------------- No. __----------__.__.___--- - ---------------- No. of compartments5�Z ---- t--------- q R. Capacity � AW-1i al Field: Distance from neares+ well--�"__:.Distance from foundation.- _ a __..._Distance to nearest lot line,_'.______... '. Number.of lines__..__...______. __-- ;-`Length of each line Width of trench. �__ //�� Type of filter material __ �- Depth of filter material_ _ Total length-___ .-_- - - 07 Seepage it: Distance to nearest well__-_ '-----Distance om f ndation_.. �__--___.D.is r�ce to nearest lot iin� _----.. Number of pits-----/-------------Lining material _ l--�---- -Size: Diameter. ----------.Depth_��. ----------------•--- �` Cesspool: Distance from nearest well___.____.__'___-_Distance from foundation_--__._---i--_.-_--Lining.material--------._---------------_------_.-. ❑ 5ize� Diameter. ----------Depth--- ----- - �:----- =--w;,t�_Liquid Capacisty------------------------•---gals. PrivDistancexfromi nearest well--------.--�"``_ -----------"-----------------Distance from nearest building-2----------------------------------------- Privy: 4" Di C6 to ne'ares- lbt line____________-_____-. _ --- --.. ----------- ------------ 'l ----•---•---•--••------••-------- a Remodeling and/or repairigjdescribe):__.-A_f------ ------ " t +_1 ---- --------------------------------- ---------------•---- --------------- R ---...- = . L - €i T-_.----------•------------..._ ------------------v. - , ---—_------- -------------------- V--•-- ---- - -----------------------------------------------------•----•---- ---- ' . Vv j r F ---- ------------------ - --– -----'- --•'-- -'--------it_._..-----•------------•-----••--------`•----•------ ..------•---------- -- ---•'----'---_-----------•--- ;>--------'--------------.- hereby certify that I have prepared'this-application and that the work will be done in accordance with San Joaquin County ordinances, State laws,`;ndrules an regulationsko theSan Joaquin Local Health District. ---------- ' or Contractor' (Signed)--------------------------- - - ------- ----- --- - - ---------- ! (Title)- - By:---------------------------------- ----------------------- (Plot plan, showing size of lot, location of Sys n relation.to wells, buildings, etc., can be placed on reverse side). DEPARTMENT'USE ONI_Y_"" ` = ---------------- DATE-=v-t T f° ----------------------- APPLICATION ACCEPTED BY___ _..___�___�.___:_ - -- REVIEWED BY----------------=--•- -- -r - -----•-•-----•----------•--=--------- --=------------------ DATE- :�=- -- ., F BUILDING PERMIT ISSUED - = - ... DATE-----------'=---------------- ------------------------------ - - - Alterations and/or recommendations----------------------- ------ - d Y L --------------------+_-__ _.!__�_._.__r. ________________----------- S p ---- --- ----- i - ------------------------------------- ---------;;�----------------------- --------------------------- -------------- __ r FINAL INSPECT10N BY:.. - - -- - ---------- - Date-----------�:�--- ?r � f SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South Amarica� Slreef' 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California 59-9 REVIBEG a-SB F.P.CO,2M&-AD 1