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FOR OFFICE USE:.- -' _. --------------------------------------------- ----------- --------- ------ �-7 �� .........._______________-..--------------- ---------- APPLICATION FOR SANITATION PERMIT Permit No, r�1 2_7 - --------------------------- -- (Complete in<'Ruplica+e) -- This permit Expires 1 Year From Date Issued 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. 003--f3U JOB ADDRESS AND LOCATIO we -.... Owner's Name � '-- --••-----•------------------------------------------------- --------------- ------ Phone.................................... f Address---------- �L �' ------------------------------------------------ -- ---------------------------------------------- - ------------------------------------------------------------ Contractor's Name.- .-- _ _ - -------- - ---------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [gam, Number of living units: ---! _ Number of bedrooms _4---- Number f baths .L-_._ Lot size .. F- -1 - ---------------------------------- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table -------- ft. i Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay Adobe ❑ Hardpan ❑ I Previous Application Made: (If yes, -----------:I No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ��-- Septic enk: Distance from nearest well---4�_'-_-_Distance from foundation----- ez.-.*------Mate tial- .e. �................`__--.. No. of compartments..___ -..............5ize.. .1�I_.-Y-.S.-...Liquid depth_--- -..- ;-------.Capacity---7n�-- Dispo Field: Distance from nearest well..-- Distance from foundation----IQ'l--------Distance to nearest lot line_"_.......... Number of lines---I--------V..... --------------Length of each line--------;_i09__`________.Width of trenth---�_-___-____---.-------.____ Type of filter material.... S' i 10 Yp I t r -'' -Dep#h of filter'material ��', Total length - --100- - - '-=---------- +---•--- 5eepa�ge-PrF: Distance #o nearest well------�6Q_`____-_.Distance from founda+ion__' ...........Distance to nearest lot line-__X'--------- ❑ Number. of pits---- ------/---------Lining material---- 4-tg`------ Depth---f�''� -------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------.____.Lining material........ ---------------------------- -❑ Size: Diameter..---i--------------------------------De th---.-----------------. . --- --- - Li uid Capacity( p - - - - - - -- q -- ------------------------gals. Privy I Distance from nearest well-----------_-------------------------------------Distance from nearest building---------_----_--------------------------- Distance to nearest lot line......................._..._._.______-___------. j I Remodelingand/or repairing (describe)------- ------- ------------•------------------------------------------- ---••------•--------•--•------------- ----------------------------------------- ----------------------------------------------------------------7---------------------------------------- ------------------------------------------------------••-------------------------------------•---•---•---•---------------------•------------------------------------------------ --------- ---------------------------------------------------- ------------------------- -----------------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, and rules and regulations of the San Joaquin Local Health District. (Signed)-- .- �----�--`_-----� ------------------------------------- nd/or Contractor) -- ------ --- - -- --- --- BY ---- ----r----------- -------- ----------------------------------------------------------- (Title) (Plot pian, showing size of to+, location of s stem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY / APPLICATION ACCEPTED -------------------------------------------------- DATE--- h - REVIEWEDBY--------------------------------------------- ------------------------------------------------------------------------------ DATE BUILDING PERMIT ISSUED----------------------------------------------------- ----------------------------------------------- DATE---- Alterations and/or recommendations:--------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------- ------•-------------- -------------•-•-------------------- ---------------------------------- ------------•----------------------- - ---------------------------------------------------- ----------- ---------------------------------------------------------------------- -------------------------------------------- --•------------------ ---------------- ---------------------------------- ------------------------------------------------------------------ ------ -- ------------------------------------------ --- ----------------- FINAL INSPECTION BY:-------. I2�1�! Date 17 -(r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.kaxetton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.Cq.