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FOR OFFICE USE: ----------------- ---------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ;--Q ---- --------------- (Complete in Duplicate) Date Issued This Permit Expires 1 Year From Date Issued 0.5`1 — CSG? 0 R 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 f ZC tom, �[4S%S-%�' f t JOB ADDRESS AND LOCATION,[_• _Y '- � - Owner's Name--------- - - - -- 5�11------------ I------------------------------------------ ----- Phone-----•-----------------•------------ a - --------- t Address • 2 -------- --- -------------------------------- F • �Contractor's Name.-- Vtff ' � ------------------------ Phone-----•••---------------- Installation will serve: Residence House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___I___ Number of bedrooms Number of baths _/____ Lot size ___________________________________________________________ Wafer Supply: Public system E] Community system /Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------I No ❑ -- New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTAL) ATION AND SPECIFICATIONS: 4) (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well--------- ------Distance from foundation-------------------Material-________---_-_-____---____________-_-__1 ❑ 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 trench------------------------------ Type of filter material------------------__-----Depth of filter material-----------------------Total length_____--__________________________ Seeif: Distance to nearest well----- f2_.__ __Distance from foundation---14__ .......Distance to nearest lot iine----__----------- T Number of pits---------/----------Lining material_____O.R_ _______Size: Diameter----� r-._--_---Depth__. _!V!__-___-____-_ -1 r ' Cesspool: Distance from nearest well-----------------Distance from foundation--- ----------------Lining material------------------------------------u ❑ Size: Diameter-------------------------- ----------Depth----------------------------------------------------Liquid Capacity-- ------- ----------------gals Privy: Distance from nearest well____----------------------------_----------------Distance from nearest building----------------------------- ____----- ❑ Distance to nearest lot line--------------------- -r-------- - -------------------------------------------------------------------------------------- ---- Remodeling and/or repairing (cJescribe)_______ 21______ ____ ----------•-------•---------------------------------- ----------------- -- -------------------------------- -- --------------------------------------- --------------------- ---------------------- i _______------------------------------------------------------_-----------------------------------------------------_----------------------------------------- _____________________________________________________ -------------------------------------_-------------------------------------------------------------------------------------------------------------------____________---- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St a laws, and rules and regulations of the San Joaquin Local Health District. (SignedII -- -- ------------- ---- ---- ------ -------- - --------------------------------------------- -------------------------------- ------------- and/or Contractor) By:-- --- -----� ------- ---------------------------------------------------------------(Title)-- ------ -------------- --------------- ------ - (Plot plan, showing size of lot, location of system n relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY q APPLICATION ACCEPTED BY A - DATE--j—� { ------------------------- REVIEWED BY------------------------ ------------------- -----_---------------------------- ---------------- ---------------------- -- DATE-------- ------------------ -------------------------------- BUILDINGPERMIT ISSUED-------------- -------------------- ------------------------------------------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations------- -----------------------1-... -------------•-•-------------------------•--------------------------•--------•--------------------- ---------------- --------------------------------------------------------------------------------------------------------------------•-------------------------- ------------------------- --•--------- ------------------------------------- FINAL INSPECTION BY: - - - <'�/ Date ? /-9 ---(` k SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West oak Street 124 Sycamore Street 205 West 9th Street 1' Stockton,California Lodi,California Manteca,California Tracy,California F.P.Cp.