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FOR OFFICE USE: Permit No. - APPLICATION FOR SANITATION PERMIT ------------------------------------------------------ -- (Complete in Duplicate) !' ed �_______' W_ __I�/ Date Issu5 __------------------------------- .._.__..___.__. This Permit Expires 1 Year From m 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. �y -- ' JOB ADDRESS AND LOCATION-------------- I -------{h a R ... ----------- ------------ --- --- --- ----------------------- � 1 r Owner's Name r"= 1� L1�1 1 �'S - Phone__ Address-------- ----------------------------------- --- - -e �n - - �� lLU - ------------------ Contractor's Name----------------------------------------�ff�A5--+...........:vj ---•-------------------- Phone- -4-------! P-f Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: '2-Number of bedrooms -3--- Number of baths 2— Lot size ------- -------------------------- Water Supply: Public system R] Community system ❑ Private ❑ Depth to Water Table 40-- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam b4 Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No I!a- New Construction: Yes ❑ No $a� FHA/VA: Yes ❑ NOV TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation_- -----------------Material----.-----------------------------------.___.._. ❑ No. of compartments--------------------------Size------------------------------..Liquid depth--------------------------Capacity----------------------' Disposal Field: Distance from nearest well----- ----- Distance from foundation___!V__.____.-__.Distance to nearest lot line----------------- Width of lines---------------I------------------Length of each line----------`��i�------.Width of trench---.--- ------------------- � Type of filter material___$---�Depth of filter material-------I��_ --------Total length-------------. __------_-____.__-___ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- El Number of pits------------------ —Lining material----------------------.Size: Diameter-----------------------Depth_-.------------------------------ Z Cesspool• Distance from nearest well-----------------Distance from foundation--------------------Lining material----------------------.___________.__. ❑ Size: Diameter------------ ------------------ Depth------ --------------------------------- ----------Liquid Capacity---------------------------gals. Privy: Distance from nearest well------------------------------------- -----------Distance from nearest building---------------------------------------.-. ❑ Distance to nearest lot line-------------------- ------------------------- -------------- ------ ------------------ --------------------------- _ �' c.�.. - --gid►.- -�.+'-�- " "^�, Remodeling and/or repairing (describe):_---____ �-_ --- - - -- ------------------ ---------------------------------- ----------------- hereby certify that I have prepared this,application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and re ulations of the San Joaquin Local Health District. a _ (Signed} ------- ----------------------------- 4(jOer and/or Contractor) ---------- i . BY= reLz---------- ------------------------ (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 APPLICATION ACCEPTED BY- ------------- DATE -sf REVIEWEDBY - ---- ------------- ------------------- DATE----------------------•------------------------------------- BUILDINGPERMIT ISSUED-------------------------- ------------------------------------------- -------------- DATE----------------------------- ------------------------------ Alterations and/or recommendations:------- -------- ------------ ------ ---------------------------------------------------------------- ------------•------------------------------------------- FINAL INSPECTION BY:...._--..eol�x _--- ------ 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 F.P.EO. C