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FOR OFFICE USE: ------------------------ --------------- --------------- 12--// r APPLICATION FOR SANITATION PERMIT Permit No. .. ......... -------------- -------------- { -- --------------- -- - ----- ----------- ------------ ----- ----- - ----- --- (Complete in Duplicate) Date Issued Date Issued ----- ------------ ---------------------------- - ----- This Permit Expires 1 Year From - 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. )q-,I/),A-) , OS/ Z t 0 --2-7 16 31 0- F-u-t 07T "j , t JOB AD RESS AND LOCATION! - A a -��". -- �------------------ --=------------------------------------------------- / ~ � I Owner's Name--- Phone s Address ------ ----- i ------•------------------------------------•------------ {-------- Phone...........--------- Contractor s Name--.-.-.. . Installation will serve: Residence lM Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ + Number of living units: -_�.... Number of bedrooms --:1... Number of.baths .-l_. Lot size . ....... ....... ._.....----...-._..._. ., Q Water Supply: Public system ❑ Community system ❑ Privates„[-De h to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ [ Gravel ❑ Sandy Loam Clay Loam E] Clay E] Adobe ❑ Hardpan � [ 4 [I ❑ 14 Previous Application Made: {lf yes,dote-----------:--------a No F1 New Construction: Yes No FHA/VA: Yes ❑ No ❑ ,Cj ' TYPE OF INSTALLATION AND SPECIFICATIONS: ! (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ✓ E Septic Tank: Distance from nearest well--_ __...Distance from foundation---/A7..�-.-_....Material------ .c.. -------------- No. of compartments---------Z------ ----Size.��._1/-_~J(..�f X-5-�--Liquid depth------ --- -------------Capacity---Ix f Dispos Field: Distance from nearest well.--_,JC1.�-._Distance from foundation----f_.�.�-.-----Distance to Field: Distance lot line.�r�.�.-_.__... ► Number of lines-----------r.-------------------Length of each line--/aO-------------------Width of trench--Z-."------------------------- - Type of filter material-------- .t- .......Depth of filter material-.: . length------1.4�-a-------------------------- Seepage Pit: Distance to nearest well..--------------------Distance from foundation....................Distance to nearest lot line----- _---------- --- ❑ Number of pits----------------------Lining material-----------------------Size- Diameter-- -------------------Depth----------- ---- Cesspool: Distance from nearest well-----------------Distance from foundation---.-----.._____..Lining material..-__-_-_--.-..__--....--- -. alk. ❑ ``Size: Diameter------ ----- -------- ------ Depth --------------- ---------- ------ ------------Liquid Capacity --------------------- g Privy: Distance from nearest well .................._-_.----.----------------- - Distance from nearest building__.__.-....------....._-..-----.-.------. ❑ Distance to nearest lot line--------------- ------------- -------------------------------------------------------------------------------------------------------------- - Remod6ngand/or repairing (describe --------------- -- ----------------- ----------------------------•--------•-----------------------------------------------------------•------------- - 4 ------------------------------------------------------ f ----------------------------------------------------------------------------------------- I ----------------------------------------------------•------------------------------------------------------------- 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 d rules and regulations of the San Joaquin Local Health District. i Contractor) nd/or for (Signed)----------------- -- ---------- By.------ �"'f = ----- {Title( (Plot plan, showing size of lot, location of system in relation wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY I" APPLICATION ACCEPTED BY..-- ' DATE--- � - �1' �------------------- REVIEWEDBY------------------------------------- -------------------------------------- DATA BUILDING PERMIT ISSUED-------------------------- ---------------- ------------------ DATE Alterations and/or recommendations:----------•---- -- -- -----------------------------•-----------------•-- --------------------------------------- ----------------- -------------•-------------------------------------------- ------------------------------------------------------------ •------------------------------------ ---------- ------ --------------------- ------ -------------------- ------------------------- --------- --- -------------------- ------- ----------------------------`-- - ----- ----------- ----- - FINAL INSPECTION BY:.._- -------- - - Date- ----------------- - -------- -------- --------------------- ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 West Ook Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California r.P.CO.