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FOR OFFICE USE: ------------:__2----------------------------- ---------- ------------------- ------------------- --------------- ----------------------:--------.--------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .-.1 ... 0 -----------------------' ---------- (Complete in Duplicate) �lL -ssued- Date Issued -_-------_ C_� I- - This'Permit Expires T Year From.Date'I 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. JOB ADDRESS AND OC TIO -__ ---- ------"-- Owner's Name ---.---- Phone ---• -•--...------• Address �(l.J L-- -.- 11! ------------------=--------------•-----.....------------------------------ ----.---------------•,-------------- Contractor's Name------------------------ ....... ----------------•----•---•-• -----------------:---------�-----...._..--•-- Phone---•._...---- _ Installation will serve: Residence .Apartment House❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other 0 .. , . % 1 Number of living units: I--_ NumUr of bedrooms_ Number of baths ./--- Lot size .��._X 1�a--.._.--__--_----------------- Water Supply: Public,:system-❑ Community,system.. Private D Depth to Water Table _ Tft Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay,Loam ❑ Clay ❑ Adobe [Z� 1 ardpan ❑ I Previous Application Made: (If yes,date---._-_.- _.--:- No �New Construction: Yes gi-No ❑ FHA/VA: Yes 0---Ko ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic,tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest wel�j.-- Distancefrom ---------Mata _�- � - ._..__- No. of compartments,_ --------- a_ _ Liquid dePh.. . - � Ca acit - _______ �--Disposal Field: Distance from nearest well------ -------- ----. Distance from foundation..- ----`-_Distance to nearest lot line-- ----- -__- Numlier of lines________ . Length of each line_____ .___ rr ❑� s�� Width of trench � •�1— p Type of filter material Depth of {filter ma"terial____- - -Total length------/1�®__f________________ Seepage Pit: Distance to nearest.well--------- ----------Distance from fo dation__., _._.___..Distance to nearest lot line___°? .__ O ®� Number of pits------- Lining material___ _ __ _-._--.Size:Diamefer__,J�g.........__Depth__. . Cesspool: Distance from nearest well-----------------DisM6i from foundation__-____ ----------Lining material---------------------------------- ❑ Size: Diameter---------------------- ---------------Depth--------------------------------------------------.-Liquid Capacity---------_----------------gals. Privy: Distance from nearest well--------------- ---------.----------------Distance from nearest building----------------------------------------- ElDistance to nearest;iot-line---_.--__::___ -- _= - -------------_-------------•----•--------------•---I--------•----------------------- Remodeling and/or repairing (descri'be);-------------- -------------••------------------------•---------- - . ------------------• ---•----------------------------------------- •------------------------ -------------------------------- ...L - ---------------------------- -----------------•--------------------------------------------------------...--------------------------•---•-------------------------•-------------------------------------------------- I hereby certify that I have prepared this applidation"and-.that the work will be dobe in accordance with San Joaquin County ordinances, State laws, and rules and r gulation of the San Joaquin Local Health District. (Signed)-------------------------- "r -- -------- -------------------------------- ----- (0—_ Contractor) BY: •-----=-=----------------------=---------------------------� �-�/ --------(Title)- �`�/ --------- - - -- -------------- (Plot plan, showing size of lot, location of system in r I ton to wells, buildings, etc., can be placed on reverse side). ( FbR DEPARTMENT USE ONLY � APPLICATION ACCEPTED BY- 0t - 7� ------=---- ----- = = DATE ----1� --------------------- REVIEWED REVIEWED BY --- ° _i ------------------------------- DATE BUILDING PERMIT ISSUED--- - ------ -------------=------------------------- -----------_------------- DATE--------------- Alterations and/or recommendations:.-. - Z 1 fa _. _______________________________________________ _--------------___ _ --------------------------.------------------- --------------- . ------------------_------------------------------------------------------_-------_-------_____________------------------------------------------_-----------------_---------- ------------------------------------------------ FINAL INSPECTION BY:. :..,..._._. Date---> --- -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,Californlo Lodi,California Manteca,California Tracy,California\ r t E9.9 REVIB[O B-59 r^a O.aM 6.60