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FOR OFFICE USE: � { f APPLICATION FOR SANITATION PERMIT - .PerT- it No. -------- -------------------------- ---"------------------- --------------------- (Complete in Duplicate) Date Issued.- .:f/ --____-___________ ________ ---- 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. JOB ADDRESS AND OCA 1 N__ L 3 � ----•--•-• ---- --------------•--------------..----------------------- Owner's Name__IlIt.__/d:-.._ Phone Address:_-_--__ _ - ------------------•---•---------------•-----•- Contractor's Name_ w------- , `fix•-----.----- - ---------------------- --------.-- Phone-----------•-----•--------•-------. Installation will serve: Residence P--7 partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [I k Number of living units: -1----- Number of bedrooms _ __. Number of baths -___ Lot size __ /_. -.X1�--------------•------•-•••------ — Water Supply: Public systemCom munity system ElPrivate E] Depth to Water Tab1e`(-;5--V ft. Character of'soil to adepth of 3 feetc Sand I] ! Gravel ❑F SandyF-oam [] Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ I :� _ Previous Application Made: {If yes,date--------________----) No ❑ New Construction: Yes [I No ❑ FHA/VA: Yes.F] No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) t Sept Tin _ Distance from nearest well_________________Distance from foundation-------------------.Material__________ _____________--._.____.._.______-__-. No_ of compartments-------------- -•---------Size--•----------------=------- -•Liquid depth------------ -------------Capacity----------------------- Disposal ------------ ------- Disposal Field: Distance from nearest well/k_ 4-e--___Distance from foundation.-_-Sd_----------Distance to nearest lot line�________- [� Number of lines---.-------A-------------------Length of each line_-3a---------Width of trench----. -y------------------ Type of filter material--te- r-- ----Depth of filter material-__f ` ..___._____Total length_____ ________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line_______.-__-___._ Number of pits----------------------Lining material--------.--------------Size: Diameter-----------------------Depth--------------------------------- �h Cesspool: Distance from nearest wail_________________Distance from foundation--------------------Lining material---------------.--------------.._____- ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity-------------------........gals. �'\ Privy:' Distance from nearest well_________.__---_________-.____----------------Distance from nearest building------------------------------------------ W ❑ Distance to nearest lot line------------------ ---------------------------------------------------- ----------------- ------ ,p Remodeling and/or repairing (describe)---------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------- --------------------------------------------------------------------------------------- ----------------------- --------------------------------------------------------------------------•------------------•------- --- I hereby certify that I have prepared this app' ation rd tha+ the w,-o- b rk will e done in accordance with San Joaquin County ordinances, State laws, and rules and regulations the S 6 Joa in Local Health District. (Signed)----•• •----------------------------------------------------------- -- ------ - - -------- ------- -------------------------------------------------------(Owner and/or Contractorl T„ By: -- -----------(Title)------------------------------- ------------- --------------- ------------------------------=------ --- --- -- ------ ------------- (Plot plan. showing size of lot, to on of system i rela ion to ells, buildings, etc., can be placed on reverse side). �Jf`FOR DEPARTMENT USE ONLY / APPLICATION ACCEPTED BY---- -- -C -/----- -- -- ----------------- -----------•--1------------------------ DATE---- ----------------------------- REVIEWEDBY------------------------- ---------------- ------------------------------------------------------------ DATE------------•----------------------------------------------- BUI LDI NG PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations------------------------------- -------- -----------------------------------------------------------------•-----------------------...------------------------- ---------------------------------------- ---------------------------------•---------------------------••--•---------------- -----------------------------------------------------------------------....-------------------------------- --... . I ------------------------------------------------------------------- ---------•-------------•--------•--------....---------------..:...... --------- ----------- FINAL INSPECTION BY:.6�7.-- Date----.-- J~ /------- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore street 205 Wert 9Th Street Stockton,California Lodi,California Manteca,California Tracy,California ES-9 REVISED B-39 F.P.CC.ZM 6.60