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FOR OFFICE USE: n6:3, ---------- -------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. -------- -- - -----------------------------•--- (Complete in Duplicate) ` S �� --- Date Issued --- This Permit Expires 1 Year From Date Issued �}f Application is hereby made to the San Joaquin Local Health District for a permit to construct and instal[ the work herein described. This application is made in compliance with County Ordinance No. 549. :765./ ET M/L6 JOB ADDRESS AND LOCATION .• -- r - ----=-----------7 Owner's Name----.--/ ------- ----- ----------------------- -------------------------------- -------'- Phone------------------------------------ .Z/ ----------------------------------- y� JAddress -------------7 - Qa " Contractor's Name-_4%k-ase' --------- -------------------------------------------------------------------------------------------------------------- Phone------._-------------------------•- Installation will serve: Residence J9 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I------ Number of bedrooms __ -._ Number of baths _L____ Lot size _ ______________________________________ Water Supply: Public system ❑ _Community system ❑ Private gi Depth to Water Table 2_P.._ ft. Character of soil to a depth cf 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe,® Hardpan ❑ Previous Application Made: lif yes,date--------------------l No ❑ New Construction: Yes ❑ No ❑ FHA/VA-: Yes ❑ No [:1• d TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest weH-----------------Distance from foundation---------------- Material----------------------------------------------__. { ❑ No. of compartments--------------------------Size------------------------------._Liquid depth--------- ---------------Capacity-------------------- Disposal Field: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line-------------- ❑ Number of lines-------•---------------------------Length of each line-----------------------------Width of french----------------------------------- Type of filter material---------- -------------Depth of filter material-------------- - ------Total length--------.________________-___--_------ Pit: Distance to nearest welL_ a- --------Distance frog foundation - ''______--_.Djstance to nearest lot line_. ________ ; ❑ Number of pits_______________ !?.r/�C________Lining material- .._-_-__-Size: Diameter_6-In-1__l------Depth___. Cesspool: Distance from nearest well-------------_---Distance from foundation....................Lining material____.._______.___._____..__-__-_.- i ❑ Size: Diameter----- -------------------------------Depth-------------- --------------- ---------------------Liquid Capacity-- ------------------------gals. Privy: Distance from nearest well ___________________---------------------------__Distance from nearest building_----___--._..__________________-_____._. ❑ Distance to nearest lot line ------------------------------------------------------------------ ` a Remodeling and/or repairing (describe)=------- --------------------------------------------------------- ------------------- ------ (\�\w --------------------------•------------------------------------------------------------------- -----;-------------------------------------------------------------------------------------------- ---- - --=----- ----- ------------------------- ------- ------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------- - -- -- ------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Court ordinances, State laws, and rules and regulations of the San Joaquin Local Health District, "��'...... n- ------- ------------------------------------------------------ (Signed)-------------- - -- --------------1--- -----------(Owner and/or Contractor) By:-----------------------------------------------------------------------------------------------------------------------------------(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_Y'-3`'-� REVIEWEDBY------------------------ ------------------ - ----- ---------------------------- --------------------------------------------- DATE----------------------------------------------------- BUILDINGPERMIT ISSUED----------------------------------- ---------------------------------------------- - ---------------- DATE---------------------------- --------------------------- Alterations and/or recommendations:-------------------- ------------------------------------------------•--------------------------•------------•--------------•-----------•-------------' ----- -------------------------------------------------------•---------------------...-•--•------------------------•--•---•----------------------------------•-------•------------------------------------------------- --------------------------------- -•---------------------------------------- -------- ------- ---------------------------------------------------------------------------------- ------------------------------ ---------------------------------- ----------------- ------------------------------------------------ -------------------------------------------•----------------- -----•---- ------------------------ ----------- ---- FINAL INSPECTION BY ----------- ------------ Date-�' `_. �' /fG - __ .C� 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 -j F.RC D. `,1 y