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FOR OFFI E USE: r ------ ------------------ ------------------------ -------------- APPLICATION FOR SANITATION PERMIT ..'Permit No. ..: -------------------------- w` + (Complete in Duplicate) a � -------------------------- This Permit Expires 1 Year From Date Issued Date Issued .... Appl cation 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 JOB ADDRESS AND LOCATION:3 n2 - ---- ,G ------`- ------------------- !� � (�`y. . ...... Owner's Name-- -------------------------------------- Phone.-•----------------------------•---- r ddress-. = --------- -----------i --- .. / -----------------------------•---•------••-----•--••----------------•-----------•--•------•- Contractor's Name. - - +frvtTtf--------------•---- ..------_'...... Phone------------....................... Installation will serve: Residence ❑ Apartment House E] Commercial ❑ Trailer Court '3'Motel ❑ Other ❑ Number of living units: __;L Number of bedrooms _3_-- Number of baths ).--- Lot size :_- �. :�" ------ -•__--_- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table-s _ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay .Loam ❑ 'Clay ❑ Adobe 2'Hardpan ❑ Previous Application Made: (If yes,date------ --------------) No [D—New Construction: Yes Eg—I o ❑ FHA/VA: Yes ❑ No [ -- TYPE OF INSTALLATION AND SPECIFICATIONS: I, (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septi Tank: Distance from nearest well-------.._------Distance from foundation-------------_-.--.Material _---_-------_.------__..-----_-..---..- U)L / f No. of compartments--------------- -- -------Size-------- •-----------•---------Li Liquid de0h q P -----------Capacity-------•------ - --•-- p a� Distance from nearest well------------------Distance from foundation__---_._-__----.--.Distance to nearest lot line....___---------- is os 1 Number of lines-1--------------------------------Length of each line------------------------------Width of trench - C' Type of filter msferial-------------------------Depth of filter material-----------------------Total length-----------------_-•---------•------------ a r See Dis#ante #o nearest well:/1 7c�------___Distan from ndation--.11l.--_-_-.___.Distance to nearest lot line.--71 r Number of pits-_-----___1----------Lining mat eri �-ZaC�t�`-.- -.Size: Diameter---��Y----_..----.Depth--..--�-U---_- Cesspool: Distance from nearest well-----------------Dista ce from oundation------------.-------Lining material------------------------------------- El -.-❑ Size: Diameter------------------------------ -------Depth----------------------------------------------------Liquid Capacity--------------------------- gals. Privy: Distance from nearest well------------------------ __------Distance from nearest building , ❑ Distance to nearest lot line Remodeling and/or repairing (describe):----------------------------------------------------------- ----------; -•--------•---------- ------------- -----------------------------------------------•--------------•---- ------------------•------------------- ------------------------i---•--------•-------------------------------•--------•-•----------•------------------•----•- --------------------------------------------------------=----•-=---------------------•-----------•-----------------•--•----------------------------------------------•-•-----------•---•---------------------------------- I.hereby certify that I have prepared this pplication and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and re lati ns of the San Joaquin Local Health District. (Signed) =------------------ -' (Owner and/or Contractor) By: ----_... ---- (Title) -------------------------------------------------- (Piot plan, showing size of lot, oca+ion of system in relation to wells buildings, etc., can be laced on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- - ---,-�----- - --- - -- -------------•------_ - S- ---- ------------------ DATE-------�Q-- --•--•--------•---•- ------------------- REVIEWED BY. ----------- ----------------------------------------------------------------------- • - - ... DATE---------- ----------- BUILDINGPERMIT ISSUED----------------------------•---------------------------- --------------•----------------------- .... DATE........ ------•--------------------------------- "� Alterations and/or recommendations:_-.%------------------------------------------- -- :::--::-- - - ------� � r-------------------------------------------------------- ------------------------------------------ ------------------ -----•--------- - FINAL INSPECTION BY:........ cl-_ ` -- Date f - ---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 41h Street Stockton,California Lodi,California Manteca,California Tracy,California EB-9 REv,9E0 9-69 r.P,oO.2M 6.60 t M