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FOR OFFICE USE: .� r,/� r.. --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ---------------- ---------------- ----------------------------------- -- - (Complete in Duplicate) Date Issued This Permit Expires 1 Year From 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. S� ----•-------------- JOB ADDRESS AND LOCATION--------7-�1---�------------------��- �-----------�------------------------•------•---------------------------------------- Owner's Name -------•------5=-------- G`'''G-------------------------- Phone Address--------------------------------------------------------------_51;:1`------- -------------------------------------•--------------------------------------------•----------------------------------- Contractor's Name--------------/-� --•-----('`'s._----•---------•- ------t ------•-----••-------------------•--••---- Phone----------------------------------- Installation will serve: Residence )d Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ----C_ Number of bedrooms ___ Number of baths -Z--- Lot size _______..�;_---- ________________ Water Supply: Public system [f Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy loam ❑ Clay Loam Ij Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: {If yes,dat��_.Z�__._} No ❑ New Construction: Yes ❑ No ❑f PHA/VA: Yes ❑ No B TYPE OF^INSTALLATION AND SPECIFICATIONS: R (No septic tank a'r.cesspool permitted if public sewer is available within 200 feet.). 114N%� S v a* � Distance from nearest_well_____-o--�-----Distance from foundation-----/_a__-___Material____ -___ _ _ __ _ _________ P �� _1 - sr X.J _Liquid depth------ Y.--------.Capacity------ 'No. of cam artments�__�."�7. ' l_- - --Size----- Disposal Field: Distance from nearest welly>__- __Distance from foundation------�t.4�p-.._.Distance to nearest lot line „ * i _ line___ __4777---- Number `____ �umber of lines----------- ---------._�°"Length•of each line_mlWidth of french-----------------L--------.-.-- Tpe of filter material___��1.__De`!.__Depth of filter material____!�-----------Total length__________________8_--!"-_`________ Seepage Pit: Distance to nearest well-.. __._ _ __I-__Distance from foundation-----_l_/r_'__--.Distance to nearest lot • d �lin_seI--------- "_ 4 -__ _______._Number of Pits._..___ t--- ---- Lining ma#eriaL_ - Size: Diameter____.- - "-- . _ Dept h------- Cesspool: r Distance from nearest well-------------' _Distance from foundation--------_-----------Lining ❑ • material------------------------------------- Size, _________________________________ Size: Diameter - Depth ------ ---------------------- ----`--------- -- -----------------._Liquid Capacity gals. . Privy: Distance from nearest well________________ "�"'_ ' " "`"'Distance-f ------------------------------------------ rom,nearest.building Distance to nearest lot line--------------I----" -----------------------%-----•----------------- ------------------------------------------ ------------------------- rItRemodelingand/or-repairingdescr�be):`� -- = --------- � L`---------------------- - . ------ ----------�------- G_..�-- x Y c= - I 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•regulations of the S u.'Joaquin-Local-Health.District. � 4 (Signed) J13 L�� f--------- _ � (Owner end/or Contractor) ---(Title)-------------------------------------------- --------------- (Piot 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------- - `'-'r----------- ---------------------------------------- DATE-------- -- -- --'------ --------------- ,�-�----- --�- REVIEWEDBY-------------------------- --- - -------------------------------- --------- -------------- DATE----- --- � BUILDINGPERMIT ISSUED----------------- ------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alferations and/or recommendations--------------- -- ------------- -- ---------------•-••---------------------------- -------------------------------------------•--------------------------- ---------------------- -•--------------- -------•------•-••------------------------------------- ----------------------------------•---------------------•------•--------------------------------------------•---------- — r ------------------------------------------------- - --------------------------------------- -------------------------------------------------------------------------•--••-•---•-•--•----•-•--- ---------------------------------- -------------- �{�,'�. ------`--------------------------------------------------------- -------------------------------- FINAL INSPECTION BY:.----- ----- -- Date------.-/ -�__Z- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hegelian Ave. 300 West oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F5 9 REVkSEO B-59 3M 3-'63 F.P.CO.