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FOR OFFICE USE: f --------------------------- APPLICATION FOR SANITATION PERMIT Permit No. -- --- -- -- --------------------------------------- (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 tb cansruc# fi a'd install the work herein described. This application is made in compliance with County Ordinance No. 549. 'x"' JOB ADDRESS AND LOCATION'-- ----------------- ----•�-- -------------- _---------- . Owner's Name----------- E Address ---------------------•------ ---------------------------•----------------- ��oo Contractor's Name---e-z------- ... -------= --- --------------------------------------- Phone-----•-•--------------------------- Installation will serve: Residence 1- Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: `_ Number of bedrooms Number of baths 1------ Lot size - --•---•-------•----------------------- Water Supply: Public system ❑ Community system ❑ Private,]`t' Depth to Water-Table 20.- ft. i Character of soil to a depth of 3 feet: Sand [] Gravel ❑ "Sandy Loam I] Clay Loam."] Clay ❑ Adobe ❑ Hardpan ] Previous Application Made: (if yes,date..--------- ,.__} No ❑ .,New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: Mw (No septic tank or cesspool permitted if public sewer is available within.200.feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material _------------------------------ ---------- El No. of compartments--------------------- ----Size--------------------------.._Liquid depth--------- --- - - ------Capacity----------------------- Disposal Field: Distance from nearest well-_X _______Distance from found ation.,f e-------_....Distance to nearest lot line-sr----------- em Number of lines---------,!✓-- --------------- ----Length of each line.._/I�--.------------.Width of trench__r�'Y.¢--------------------- CI Type of filter materia yp �-- --------------Depth of filter mate ial.-..-/?....-....---- otal length_.-. -------------------------- Seepage =------------------"-----Seepage Pit: Distance to nearest well..............______Distance from foundation-------------.------Distance to nearest lot line----------------- 171 Number of.pits---------------------Lining material-----------------------Size: Diameter-------------.---------Depth-------------------------------_- Cesspool: Distance from,nearest well-----------------Distance from foundation--------------------Lining material------------------------____--.-....- Size: Diameter---------------- --------------------Depth-- --"_Liquid Capacity __.....gals. Privy: Distance from icearest well------------------------------------------------- from nearest building...-"----__.__________-------------._.... ❑ Distance to nearest lotline----------------------------,------- - - -------- ----- --------------------------------------------------- - Remodeling and/or repairing (describe}:-._.--. ___r_ __k!'--- _-- _._ Rf` ----------------------------------------------------------------------------------------------------------•------------------------------------------------------------------------------------------------------------------ r I hereby certify that I have prepared this application and that the work will-be done in accordance with San Joaquin County ordinances, Stat laws, and rules and regulations of the San Joaquin Local Health District. (Signe( ) --- (Owner and/or Contractor) 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 ,i' . ------------- -------------------------------------------- DATE..4s.--- -'"------- -------------------------------- REVIEWED BY----------------------------- - ---- --------- ------------------- DATE BUILDINGPERMIT ISSUED =`-------------------------------------------------•--------------------------------------- DATE------ ------------------------------------------------------ Alterations and/or recommendations---------------------------- - - -------- ------ -----------------------------------------------------•------- ---------------•----------------_------------- ----------------------------------------------------------- ---------------- ------------------ ---------------------------------------------------------------------------------------------------------------------------- la 1 q ------------.-------------------------------------------....------------------------------------------------------------------------------------------------------------------------------------------------------------------ , ---------------------------------------...-----------------:-----------------.-----------------------------------------------------------.---------.--------------•--'------------------------------------------------------- ---------------------------- -------- ------------------------------------_----------_._--------.-_------_---_---------..-_------------------------------------------------------------------- FINAL INSPECTION BY: ---------- Date -1�_'� -- SAN JOAQUIN LOCAL HEALTH DISTRICT ;i 1601'E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CO.