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FOR OFFICE USE- ------------------:----------------------- SE:------------------=----------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ------------------ --------------------- - ----------- 1 (Complete in Duplicate) 1/, (� ------ ------------------ 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. O ---- ------.--ev � JOBADDRESS AND LOC TI _Q,41,---------------------_---------------------------------------------- -------------- ------•-•-----------•-•-----------------------••--------------------------------Phone ---------------------------- ." : Owner's Name �� ----------••• Address......... ------ - ---------- -- ----------•---------._---------------------------••---------------------------�._ one IL Contractor's Name----- •--- _& ------- "�- ----------- -• ="_ ..` . Ph Installation will serve: Residence ®impartment House ❑ Commercial ❑ 'Trailer�Court ❑ Motel E] Other [I Number of living units: ___ __ Number of bedrooms J-_ Number of baths Lot size _. _ X.' -------- ------------------ Water Supply: Public system ❑ Community systemPrivate ❑ Depth to Water Table _ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel [] Sandy Loam ❑ `Clay Loam ❑ Clay E] Adobe Hardpan CI Previous Application Made: (If yes,date.-__,_--------------} No 2---New Construction: Yes ®_Vo ElFHA/VA: Yes [] NO ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: . (No septic tank,or cesspool permitted if public-sewer is available within°200 feet.) i Septic Tank: Distance from nearest well--____.._--_-_-Distance fRm foundation--__161-__---Material ..�1/�'_J-5 ._.--__----.,�Na. of compartments Size 6� � Liquid depth {--� ----------- CapacitY Disposal Field: Distance from nearest well..........----- -Distanoe.from foundation-------- -----------Distance to nearest lotfline:._ _._-----_--. 1 ( Number of lines---------�--i-- -- -- - _Lengtb,of each#line---_ 7j_-_-!- --� Width of trench-----=2------------------------- --------------- Type ------------------------ --� ._ J Type of filter material_/_,-/�QG�'.Depth of filter material_____/ ----- length---__1* _______________ Seepage it: Distance to nearest well-_-_--�—_------Distance fr m fou dation:__A2-------.Distance to nearest lot line~-� �� Number of pits- _-__.___.,__Lining material___ _________ ______Size: Diameter_s.� _.____...___.Depth----- ►�`____-------------'� Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--__--_----__.----___--.---_------_-. I ❑ Size: Diameter-------------------------------------Depth---------- ----- -------------------- -------------Liquid Capacity-------••---------------•---gals. Privy:: Distance from nearest well--------------------------------------------------- nearest building--------------------------------_.._____- [� Distance to nearest lot line - ---------------------------------------------------------....... ------- /151 Remodeling and/or repairing {describe)--------------- _ -- -------------------------------------------------- k -----------------------------------------------------------------------------=�------_____.______A_-_______._______________.___________------___--------------------------------------------------------------------_--------- -------------------------------------------._---.-__-_-_.-----_------____-_----______---_-_-_-__-----_______-----_--_-_-_-_-_-_-____------_-----__--_-----__---_-_-___-_____--------_.__---_-_..___._-_- 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 regulationssr-of the.San Joaquin Local Health District. ,' �r-Contractor] (Signed) ;: - - -- - -•--•--'--------• =---... BY:-------••------------------------------------------- - -- (Title) - (Plot plan, showing sizer of lot, location of syst in relation to wells,-buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY ' 161- APPLICATIQIV ACCEPTED BY A - -_ - - ----- ----------------------------- DATE ~ ' ------------=--------- REVIEWEDBY------------------------------------------------------------------------------- ---------------------------------------------- DATE---------_--•----------------------------------------------- BUILDINGPERMIT ISSUED-------------------------------------- ---------------------•----------------------;------=---- --- DATE------------------------------------------------------------- Alterations and/or recommendations-------------------=----- -- '- ------------------------------ ------------------------ ------ -- ------------------------------------ i FINAL INSPECTION BY: -7 O`---- --------� Date / - �----- i SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California E6.9 REVI9E9 a-69 V,P.CO.2M 6.66