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FOR OFFICE USE: -------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ___,2. _: --------------------------------------------------------- Date issued .... ------- (Complete in Duplicate) - - . '°l This'Permit Expires l'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 Ordinance No. 549. i AF �,o --- -_ - - - - JOB ADDRESS AND 'OCATIO ---�---- -- ---- - - -- -.- - - - -•-• -- ; �"---------- --- -- ----- ;' ----------° -`= `---- ------------------- Owner s Name--- Phone_.__.._.. 3 Address ®�FA _ - . .. f .. Y Contractor s Name------- - --------------------- - ___._. Phone---------------------------------- Installation will serve. Residence [Apartment House"❑ Commercial 0 Trailer Co'urt'[] Motel ❑ Other ❑ Number of living units: �___ Number of bedrooms . -_ Number of baths _�____ Lot4size _ -�• ----••-- Water Supply:' Public system 0 Community systemrlvate ❑ Depth to Waterjable '7�4. Character of soil to a depth of 3.feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe2--nardpan ❑ Previous Application Made:' {If yes,date-------------------- 'No [r�"New Construction: Yes' gg�P'No ❑ FHA/VA: Yes I;�- No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: I No septic tank or cesspool ermitted if public sewer is available within 206 feet.) Septic Tank: Distance from-nearest well---_77" :___Distanceef�m foundation---/0____---Matesial___�►_�r _________- No. of compartments___,e��______________----Size>�-___ 4>9-:---Liquid depth_ - Capacity_��e__-___ - ----------- Disposal Field: Distance from nearest well____ "�__---:Distance from foundati n_____ef40______-D+stance to nearest lot line__._..... Number of lines__________________ _ ________ _ Length of each line__ ---------------Width of trench. Type of filter material_ Depth of filter -------Total length---/�O-p----------------------- Seepage Pit: -Distance to nearest-well-------`-'-_____Distance f m foundation____! ___...Dls a fire to nearest lot iin�e________________ Number of pits---A____________Lining rriaterial.. .-Size: Diameter-.-bc ------ Cesspool: Distance fi-om nearest well__ __ _________Distance from foundation _ - material Size: Diameter--------- --- - -- _---- --- -Deth------ ---------------------------------------------Liquid Ca ty—---------••----------❑ � } gals. 4 2 _ � - PrivDistance from nearest well________________'__:____-----____----------- --Distance from=nearest-building__`__________________________-_____-__-_. Privy ❑ ��- -- "'Distance to nearest lot line -7--7777"-------- - -------------�:_-----------------r-----._ .._--=---=---------- -------- --------•--------------------------- Remodeling and/or repairing (describe):- � L �r' =----•----•-•-------------•-•---------------------•--------- sw -------- 1 ____ _________ ., ; I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County s ordinances, State'laws,'and rules and regulations of the San Joaquin Local Health.District. (Signed T r------------ -----------------1-------------A--A.Owner�ant�,or Contractor) - j l --- tie ------------ --- -"------------ By----------------------- -_-----------=----------------------Y ( ) (Plot plan, showing size of lot, location of sys ren in relation to wells, buildings, etc., can be placed on reverse side). — + FOR DEPARTMENT USE ONLY APPLICAT]ON ACCEPTED BY i cnJ C�I DATE-. `}- �-`----- ---`- ---------------------- - --f- REVIEWEDBY--------------------------------------- -` '-------------------------------------------------------------•----------------. - DATE-------•------------- ------ BUILDINGPERMIT ISSUED------------------------`---------------------------------------------------- ------ DATE--------------------------------------------------------------- Alterations and/or recommendations: ----- =-= - ---------- ------------ •----°----_-:__---------------------•-----i----- --------------------------------------------------- _ F _ _ ----------------- ____ __ _ _ __ ____-...____________________--_------ � --"--- - --------------- ,. <a4+, L . c -------------------------- . ; FINAL INSPECTION 'Date. .-- ------r=6-/ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ` ` ' 30'0 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES-9 REVISED 6.59 F.R.CD.2M 6-6C