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FOR OFFICE USE: / --------------------------------------------------------- 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 to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. Al �s 1�la� S JOB ADDRESS AND LOCATIO .ltf_ rt��__ � _ .. -- !'��4_. _. - -I - c�-� '�- ___ Owner's Name d---- 1: ------- ' ----- Phone--------------------••-------------- } Address _ -- ly ---------------------------•••-----------------•------------------•----------------------------------- f Contractor's Name-------(sa�.� p-- ------------------------------ -----,a �d1. ---------•--- Phone----------------------------------- - - ------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court E] Motel ,[] Other ❑ Number of living Units: l__3_ Number.-of bedroom___ Number f baths _ Lot size ______/__ _________________ ------------------- Water Supply: Public system ❑ Community 'system ❑ . Private De;'Clay Water Table _----_- ft. �., } Character of soil to a depth of 3 feet: Sand ❑ Gravel-❑ Sandy Loam Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date'-___--- -_'::_..__1 No ❑ New Construction.. Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ E t TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic fink or'cesspool permitted if public sewer-is available within-200.-feet.)_ } ' Septic i nk: it 'Distance from nearest Distance from f jundatlon-_-/4?-----_____.Material---- _ _ _ ___ _______,r______--.-___. No. of compartments �____--_ Size__ .el!`� x, _Liquid depth______ ___ ______ .... �' p -- - -- �••--- --- -- � - - Capacity--- 27�- - p �}' 4 �'.�___Distance from foundation._f�_ ........Distance to nearest lot Iines_/_________ • ; ---1-3-- _ --____--Length of each line-----�-Q__`-------------Width of trench--�_--1-------------------- Type _.-_________-__-- 1 Dis os Field: Distance from nearest we ..-.___n Typebof filter nmaterial------ �_''_`-_____Depth of filter material---.1.g____---------Total length--- --- ------- -------------_____- Seepage Pit: a Distance to nearest wefl-------_--------------Distance from foundation--------------------Distance to nearest lot line________________- ❑ Z- Number of pits------------------- Lining material----------.----------- Size: Diameter------------------ ---_Depth-------------------------------- Cesspool:-'- Distance from nearest well_________________Distance from foundation---------------------Lining material___--__________----____-____-.-_____. ❑ � Size: Diameter________________________ ----------- Depth----------------------------------------------------Liquid Capacity-- --------r---------------gals. Privy: s Distance from nearest well------_------------------------------------------Distance from nearest building-------_------ ------------------ ❑ Distance to nearest lot lire------------------ - - ------ ----------------------------------------- -------------- k Remodeling and/or repairing (describe):---------------------------------------------------------------------------------------------------- -------------------•---------------------- } -----------------------------------------------------------------------------------------------------------•----------------------------------------------------------------------------------------------I----------------- ----------------------------------- ---------------------------------------------------- ---------------------------------------- ------------------ ------------------------------------------------------------- 4 1 hereby certif that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State aw and rules and regulations of the San Joaquin Local Health District. .mss (Signed) ------- ------------------------------------------------------------ ---------------------��----.- ----------------------------------- r-,!nte#:�or Contractor) itw. v*. f ^�___ _=� -_--__ __________ ________ __ ______ -------- ___-( )+R ---------- (Plot __ _ - (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 -------------------------------------------------- DATE- + ------- --------N--- REVIEWEDBY----------------------------------- --------- - -- - - ---------------------------------------------------------- DATE---- ------- -----._..------------------- --------- - --- BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------- --------- DATE------------------ } Alterations and/or recommendations------------------------------------------------------------------------------------------------ ------------------------------------------- ------ --------------------------------------------------------------- ----------------------�- --------------------------------------------------------- �11----------------------------- --------------------------------------- --- ------------•-- ----------------------------- --------------- ----------------------------------------------------------------------------------------------------------------- - -------------------- -- - --------------------------------------------------------------------------------------- FINAL INSPECTION BY:. ._ ._ .- ----------------- Date.f� �_d--6-�-----------------------------------------� a SAN JOAQUIN LOCAL HEALTH DISTRICT D 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California �r�,.. r.P.❑o.