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FOR Of FICE USE: G� :3c F E ? -- ---------------'--- '' Perrgj# No.y,��..1�...`....� APPLICATION FOR SANITATION PERMIT _ V (Complete in Duplicate) Date Issu' ?1''.._.. t 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 N nce witountY OrdinanceNo. 549. __ --------- -• ---- �-----------------------------------------•--------------- JOB ADDRESS AND CATI - = ------- Phone------------------------------------ Owner's Name// A ---------------------- Address------{ A-;7-------- ' Contractor's Name---------- ------------------- Phone................................... Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/. Number of bedrooms .-C;Z Number of baths ._./-- Lot size ---, -, .-/..l-0-------------------------- Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table Sd ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe B----Hardpan ❑ Previous Application Made: (If yes,date--------- ----------) No ❑ New Construction: Yes 2T- No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) f Se tic T k: Distance from nearest well Distance from foundation-_34---------Material--- P No. of compartments-_.- >ZP-- -----------Size-- 5 9------...Liquid depth----�--- Capacity.....go j ell Disposal ield: Distance from nearest welll_?Zd'Il�Distarce from foundation. Q-------.-.Distance to nearest lot line..---------- Number of lines---- ..I Length of each line_____ _Q-/.�---- ----.Width of trench---;7_fQ--•_-�----�____-_-.- Type of filter material......... . _Depth of filter material If length_____f ____ ----.If Seepage it: Distance to nearest well Distance � ��f°°��ndation �D--------.Distance to nearest lot line ...... J U Number of pits._/__-_____._-Lining material.��!�_-.size: Diameter---3-.�_--__...__Depth_..._�.��_______________ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material____--__-__-____._______-____-_-_. ❑ Size: Diameter----- --------------- ----------------Depth---------------------------------------------------Liquid Capacity-------- -------gals. , Privy: Distance from nearest well --- --------------------------------------------Distance from nearest building-____-___.__--_--------_--_--------_J� ❑ Distance to nearest lot line-------------------------------------------- -- --------------------- ------------------------ --------------------------------------------- Remodelingand/or repairing (describe):--------- --- ----------------------------------------------------•-------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------- - pp ---------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------- ------ N ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --- I hereby rtify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances,- a law , an'd rules nd r ulations of the S Joaquin Local Health District. (Signed) - --------- - - - - - (O ner and/or Contractor) BY: -- - -- --- ------------- -- - --- (Title) - Plot plan, showing size of lot, loco+ion of s+em in relation to s, buildings, etc., can be pl ced on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY____-___._. . . �C / ` :� —_:: DATE-------- REVIEWEDBY-----------------------------------------•------ -- - ---------- DATE BUILDINGPERMIT ISSUED--------------------------------------------------------------- ---------------------------- --------- DATE---------------�---------- �------------------------/ Alterations and/or recommendations:__ ___ __. _ - -----•---__--- - -------------------------------- ----- -�`--s`=----L---- ` ' ---- ---• --- ---- ------------------------------------------------------... ----- --- ------------ FINAL INSPECTION BY:__- _______________-_____ _ ------------------------------- Date_.... l ! C ----------------------------••-- AN 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.