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O OFFICE USE: ll- ---------------------� , o------ >�' APPLICATION FOR SANITATION PERMIT9os _______________________ _..__... - ---------------------------------------------- - (Complete in Duplicate) Date Issued .______________ ------------------------------------- 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 CountyOr finance No. 54Y. JOB ADDRESS AND OC TION__ Owner's Name-------- f ..... -----------------------------I--------------- ----- Address---------G -----------------------------------------------------------•----------------------------------•--- Contractor's Name....�-r _ --------------- Phone------ --- ------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel p O e /____ Number of baths Number of living units: ____ Number of bedrooms ,? S-._ Lot size �__a -! _ ______________________________ Water Supply: Public system WOOIC-ommunity system ❑ Private ❑ Depth to Water Table f+. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe POOHardpan ❑ Previous Application Made: (If yes,dgte--------------------) No New Construction: Yes ❑ Nos�'FHA/VA: Yes ❑ No R?- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or,cesspool-permitted if public sewer is available within 200 feet.) Se is Tank: Distance from nearest well_________________Distance from foundation--------------------Material------------------.-_-.----____-._-_-_---__.----. J 4*401�-- No. of compartments-------------------------Size-------------------------------Liquid depth------- --..---Capacity------------------ -•-- Dis osal 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------------------------------------------- Seepage Pit: Distance to nearest�/well___-._.__.._ __Distance fr fo ndation__ a.__..___.Di t ce to nearest lot line___._._ Number of pits.-_-F--------------Lining material_ ---Size: Di ameter__� ------------Depth,,;?�,,>7 Ij Cesspool:: Distance from nearest well-------------- from foundation--------------------Lining material------------------------------------- w ❑ Size: Diameter--------------------------------------Depth------------------------------------ -------------Liquid Capacity---------------------------- gals. P Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------.---------------------- ------ N ❑ Distance to nearest lot line ------ ------------p-------------------------•------------------------------------------------------------------------- Remodeling and/or repairing (describe) �� fa��fi" '�G�l --------------•-----•--•-------•----------•-••--•----•-- ...............I-------------------- ------------------------------------------------------------------------•- ---------------------------� ----------------------------------------------------------------------------------•-----------•------------------------------•------------•-----------------------------------------------•-------------------------------- ------------------------------•- ---------------------_------------------------------------------------------------------•------------------------------------------------------------------------------------------- A 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 egulations of the San Joaquin Local Health District. (Signed) - - --- ------ -- ----- --- ----------------------------- Z}f—� or Contractor) By................---=-=--------------------------------------------------------------- -- --- --- (T'i+le) ------------ - - --- --------- (Plot plan,showing size of lot, location of system in relatio wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- ------ --"-- ------------------------------------------------ -------------- DATE---------f/_�r REVIEWEDBY--------------------------------------- ---------------------------------------------------------------- .-------- --------- DATE-------------------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------- -------•--------------------------------------- DATE------------------------------------------------------------- Alteration and/ r re 0m,I do s:------- --- ------------------------------------------------------------------------------------------------------------------ � r FINAL INSPECTION - Date 7 f l!/_�1 ------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT / _.. 1601 E.Hazelton Ave. 300 Wett Oak Street 124 Sycamore Street205 West 9th Street Stockton,California Lodi California Manteca,California Tracy,California F.P.C❑.