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F,O�R OFFICE USE; .�. - APPLICATION FOR SANITATION,PERMIT Permit No. ........:............... 44 -------------------- ----------------------- (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 LOCA.LION------ --------=J--------------`------- �'1�' ------------..._ --------------- Owner's Name----. .��C��-�'-------�1--A--------- -------- -------------- V = Phone --------------------- Address = -------• --- 1 '71 = = - Contractor's Name__. . ----�---.- d Phone................ . Installation will serve: ;Residence partment House ❑ 'Commercial ❑ Trailer Court r] Motel ❑ Other ❑ Number of living units: ___: Number of bedrooms -__4--Number of baths I-_._ Lot size ��__�___,,l�----------------------- Water Supply: Public'system _ ommunity,syste_m_❑ . Private ❑ 4 Depth to Water Tablet. Character of soil to a depth of 3 feet: Sand ❑j Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: (If,yes,date-..___._-.. - No New Construction: Yes g,,I to ❑ FMA/VA: Yes ❑ No TYPE-OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material--_..___-._.---.-_..____._.------.--__--_.-_._-. ❑ No. of compartments s Size ------- .Liquid depth---------------- ---------Capacity------ ----------- Disposal Field: Distance from nearest well..:.r--Distance from foundat' n.__ _ / Distance to nearest lot)ine.:�- -- .r� Number of lines--------------- Length of each line �____.___�_ _._.Width of trench-_-_ Type of filter ml Total_-_--Depth of filter materia _ ._._Total length______ _______f_________---_-_-----_- r 1 --- t �Seepage Pit: Distance to nearest well------*--------------Distance from foundation____._..._---------Distance to nearest lot line----------------- ❑ Number of pits-----------------------Lining material-------------------.-- Size: Diameter-----------------.-----Dept n----------------------.---------- Y Cesspool: Distance from nearest well---------------:_Distance from foundation_-----_-_ .---_--.Lining material------------------------------------- El Size: Diameter----------------------i----------- - Depth---------------------------------- ---------------Liquid Capacity-----------------------------gals. Privy- Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ Distance --- ----------------------------------.Distance to nearest lot line---------------------------------------------------------------------------------4-- - --------------- ' -f---------- ribej:-Remodeling and/or repa Ing (dosc - •-- ------- -------------- F- -------------------------- I - ---------3---------------------------------------------------------------------- - }'------------------------------------------------ ---------------------------- I hereby certify that I�ve�repared this flon and that the work will be done in accordance with San Joaquin County ordinances, State laws, art ule aAsysfem San Joaquin Local Health District. -� - ---------- - (Owe and/ Contractor) (Signed)-•------------ By:------------------------------------------ - -------- ---- -------------------{Title): --------------- (Plot plan,-showing size.of.lot, locatn relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- ------- 'GIZ-f1�---------------------------------------------------------- DATE-------- 1;3--------------------------- REVIEWEDBY-------------------------------------------------- --------------------------------------------------------- DATE:---------------------------------------------------------- BUILDINGPERMIT ISSUED------- ---------------------------- --------------------------------------------- ----------------- DATE--'>....I----•--------------------------------------------- Altera+ions and/or recommendations---------------- ----------------------------- ---------------------------------- ------------ ------------•--------•------•------------------------------ ------------••------------- ------------------•--------------------- - ------------------------------------------------------•----------------- ----------;-------=-------- ----------------------------------------- -------------•-------------•--------- --••------------------------ -------------------------=---------- --------•--------•-----------------..:_.------------------------------ -•-------------------------- aY -----------------------------------------------------------------------------------------------------------•-----••---------------------------------...-----------------------•----------------..-----------"-----..___.-_.-.. FINAL INSPECTION BY:...... �c. ------ - - Date.... - - - --------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 ArVISEO 9-54 3M 3-•63 r-R.CP.