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FOR OFFICE USE: �. S ----------- ------------------------------------ APPLICATION FOR SANITATION PERMIT Permit No. ..l-.-7 __. ._G ------------------------- ------------------------------ {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 LOCATIO�--C_Lrtz_-J-/.-ICGl -------------�Tl�c�_�_._ --•---------- Owner's Name---------- '= ---------------------------------------------------------------- ---------------=------- Phone-------------------------------- Address---------- f /J -------= � l—'� Contractor's Name---------------•---------r -C ----------------------------------- ----- Phone....---------••--------- - Installation will serve: Residence 0 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __(-___ Number of bedrooms`__.,�__ Number of baths ______f Lot size ------ `.—________________________________ Water Supply: Public system ❑ Community system ❑ Private-0 Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 0 Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date---=---------------- No 'New Construction: Yes E _o FHA VA: Yes ❑ No [?f TYPE OF INSTALLATION AND SPECIFICATIONS: - '(No septic`tank or cesspool permitted if public sewer is available within'200 feet.) ' Septic Taw: � Distance from nearest well-----------------Distance from .foundation................__Material---------------.-------------------------------- . No. of compartments--------------------------Size-_--- --------------------Liquid depth--------------- _------Capacity----------------------- Disposal Field: Distance from nearest weE0_._7�7__fDistance from foundation...___..�r5_-__.Distance to nearest lot line__�'��________ � } `#INumber of lines__________3_____________________Length of each lineG , '�Ia '-�U --Width of trench._____: z 0 �� d � Type of filter material__ _ � �_______Deptli-of filter material__�.�_________.____Total length_____ a�' Seepage Pit: Distance to nearest well---------------------_Distance from foundation--------------------Distance to nearest lot line_______._______._ ❑ Number of pits----------------------Lining material-------_---------------Size: Diameter.----------------------Depth-------------------------------- Cesspool: Distance from nearest well____________`_-_Distance from foundation--------------------Lining material___-__-_____--_------------------._-- Size: Diameter--------------------------------------Depth-------------------------- -- ---------------------Liuid Capacity_ __gals. Privy-- `'- Distance from nearest.well--------------------------------------------------Distance from nearest building_.-__.___.______________________..___..._. #� ❑ Distance to nearest lot line------------------- --------------------------------------------------------------------------------------------------- ........----------- Remodeling and/or repairing (describe):------- `.__s__� + '_ r ----------------------- --------------------- ----------------------------------------------------------------------- ------------------------------------------------------ ` 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. i�__ ce ----------- - - ____Owner and/or Contractor 'I —By;._-_----------------- ---=--------------------------------------------=------------_--------= ------- -----(Title)=-=-----_------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 1 r FOR DEPARTMENT USE ONLY --- --------------- �;---------------------------------- DATE ACCEPTED BY________________________ - REVIEWED BY-------------------------------------------------------------- - ------------- --- DATE BUILDING PERMIT ISSUED - --- DATE------------------------------------------------------------ Alterations and/or recommendations:------- ------------------- ------------------------------------------------------------------------- i --------------- -------------------•------------------------------------------------------------------- --------------------------------------•-._----------•-----•-------•------- --------------•--•--.--- t -------•----•---------------------------- ------------------------------- -- ------------------------------------ ------------------------------------------------------------------------ ------------------ ------------------------ I ----------------- -------- ------== - -------------------------•-------- -------------------------------------------------------• ---•------ -- I J FINAL INSPECTION BY:----- --- Date__------- ---•- ----"----------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REv,9E0 B-59 3M 3-163 F.P.CC.