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FOROFFICE USE: - - ------ y APPLICATION FOR SANITATION PERMIT Permit No. ---- ---- -- (Complete in Duplicate) Date Issued -------------------- -- ----- --------------------------- This Permit Expires 1 Year From Data 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 LOCATION------__ ss �C2-----/ --•----- Owner's Name � �,�___�- ----- Phone-12V,, t� Address----------------------' ----- tIlt --------- '"' iC! '° ------------------------------------------------------ Contractor's Name------------ =,-t---f--__ ------------------------------------------------------- Phone'�_"_?A�7 Installation will serve: Residence ❑ Apartment House ❑ Commercial X Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __1_._ Number of bedrooms ___`)'Number of baths _1.._ Lot size ----------/6x_ __ 4__________ Water Supply: Public system A Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑4 Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date.........------l_....,_) No [�C New Construction: Yes ❑ No 1�5 FHA/VA: Yes ❑ N 01 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 ___._._______-__.______._.______._.._.______._. ❑ A'/�T/.'V. No. of compartments--------------------------Size--------------------------------Liquid depth-------:- ---------------Capacity----------------- Disposal Field- Distance from nearest weft---------------:_Distance from foundation___- _0--_--__-.Distance to nearest lot Number of lines-___________.-/________________Length of each line_______ _�?'_.Width of trench.___�_,�`le___-__.____ Type of filter material_____51'4P4�.__Depth of filter material-.---%l? o'______-Total length_______''/�C-____`_____________________ - -w. . Seepage Pit Distance to nearest well----------------------Distance f foundation /,P----------Distance to nearest lot line_._____.______.__ t Linin material- Tr l]iamete,r__ _ _`�...__:De Number of. pFts • g P " Cesspool: Distance from nearest well-----------------Distance from foundation-------------------Lining material--------.---------------------------- 10 ❑ Size: Diameter_ --' ---- - ------ - -------------Depth-------- ----- -------------------------------------Liquid Capacity_--------------------------gals. Privy: Distance from nearest wel3-----___-------____------------------------------Distance from nearest building_.,--------.------------------- --... ❑ Distance to nearest lot line-------------------- ------ --- - -------------------------------------------------------------- ---- ------------------------------ Remodeling and/or repairing (describe}:---. f)----- . 1 _r_L` -- -------- 4 _ _ rX ��--------------------------------- t x h -------------------------------------------------------------------------------------- ---------------------------------•-------------------------------------------------------- c-------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St s, and rules and regulations of the San Joaquin Local Health District. (Signed)------------- if 5 �7____ ------- A. �----------------------------------------------------------- �_____ � _(O—ger and/or Contractor) BY _�- -------- -------- ,-e .- --- {Title) (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 OOF APPLICATION ACCEPTED BY ----- - - DATE /Z �f--------------------- REVIEWEDBY--------------------------------- --- --- ----------------- - ---- -------- ---------------------- ----• DATE-------------- R--'--------------------------------------- BUILDING PERMIT ISSUED----------------- - ---------- DATE----------------;- r Alterations and/or recommendations-------- - : : ...:.......__. ---------------------_ .- "'-.."" ------------ ------------------ -- ». -----------------------------------------------•--•-------------------------------------------------------------------------------------------------------------------------------------------------------------------------- �. 1 ----------------------------------------- ------------------------------------------------------------------------------------------------------------- -------------------------- ------------- ---------------------------- FINAL INSPECTION BY---------- ------ ------------------- --�___ 5 Date---- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hoselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.C13.