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--------------------------------------------------------- --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ------------ ---------- ----------- -----« ------- (Complete in Duplicate) This Permit Ex ires 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 ovorkherein described. This application is made in compliance with County Ordina e No. 549. JOB ADDRESS AND LOCATION. �, � (0G r ----------------------------- - --•--- • ---------- ---- --------------------- - Owner's Name-------- �t ►L � 'GQr---- -------------------------------- --------- -- ----------------------- Phone ---------------------•-------------- Address--------------------- 2 r -------------------------------------------------------------------------------------------------------------------------- f ' Contractor's Name------- _- -G------------ ------- ---- Installation will serve: Residence � P+partment House E] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -)---- Number of bedrooms?--__ Number of baths-- Lot size ---/_�'�__x-- ---� Water Supply:Supply: Public system E] Community system ❑ Private Q---D—epth to Water Table.- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [Y Hardpan ❑ Previous Application Made: (If yes,date--------------------) No Lys New Construction: Yes Aldo ❑ FHA/VA: Yes [�o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well---,P.t______Distance from foundation__ Q-_/----__ Material- No. of compartments-_J-------------- -----Size-,�f-,5Z,/_._V_Q____Liquid depth_-?%----- -------------Capacity-.-�- ------ Disposal Field: Distance from nearest well, ------ Distance from foundatior/_p/_____---._Distance to nearest lot line---5'- ...... Number of lines---.,3---------- Length of each line-- l---------------- 9 �f-1Fa �----Width of #reach.-_�--��--.-�!.-------- ---- Type of filter material---/-Z2.> -_-Depth of filter material.-.� _j._______.Total length------ � ---- _/------------------ -----------if: Distance to nearest welt-----------------_---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------------------------ ❑ Size: Diameter--------------------------- ----------Depth------------------------------------ --------Uquid Capacity-------------- -------------------- -----gals. Privy: Distance from nearest well-------------------- ------_--------_ --_ -Distance from nearest building ❑ Distance to nearest lot line... ------------------------_._-_ _- Remodeling and/or repairing fdescribe):------ -- ------------------ -------------------------------------------- ------------------------------------------- ----------------- -------------------------------------------------- ----------- - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State la s, and rules and regulations of the San Joaquin Local Health District. (Signed) (Owner and/or Contractor) d 9 )---------- -- -- --- -------- ----------------------------------------------------------------------------------------------------------- - Br----------------- -- - -- -•----,�--- (Title) fl. - ---- =- - -- --- --- -- ------ ---- -----[ )--- - L�(Plo+ plan, showing si o lot, location of system in re fon to wells, buildings, etc., can be placed on reverse side). 1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY � � --- ------------ DATE--- jl 1( REVIEWED BY--------------------------------------------- ---- --------------- ----- - - ---------. DATE----- - -- - --- ----- - ------------ - BUILDING PERMIT ISSUED---------- ----- ------------------------•--------- --------------- ------------- DATE.-------------------------- tera+ions and/or recommendations--------------------__-._-.. FINAL INSPECTION BY:.- Date--/-/ -- '^ ----- 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 F.p.CO.