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FOR OFFICE SE: --- ----- ------rile'/_v j------ -f___ ______��_q f___-_/�_�/_ APPLICATION FOR SANITATION PERMIT Permit No. ._.2,a..6-6.. ---------------- - - -- - - - - - - - (Complete in Duplicate) 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. JOB ADDRESS AND LOC," ION... -x- Address y_ = ---------------------•-----•---------_____-j-------------------•------------- Owner's Name F rel ------------------------------------------------------Phone-- Address-----•-----•--•--•--•---------------•----•---. L.......... � f Contractor's Name ' `�`� --------------------------------------------•------•-----------•---- Phone................................... will serve: Residence M AparTment House ❑ Commercial ❑ Trailer Court ❑ otel ❑ Other ❑ Number of living units: ___(____ Number of bedrooms -4- Number of baths ----)_._ Lot size .___ -A..... ______________________ Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table ........ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) 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 Tank: Distance from nearest well _ k,Distance from foundation____._.�o___.__.MAiter�aL_.__-.&1,11 _ _ --------- No. of compartments-----------a----------Size--------------------------------Liquid depth-------------------------Capacity-3, P-q., Disposal Field: Distance from nearest well---t4r-y -Distance from foundation...._O-----------Distance to nearest lot line.--,...... Number of lines________________t___p_,_�_____ Length of each line_________ t f Width of french..........2..`;___-___-_____________ Type of filter material___ p_ C. -._._Depth of filter materiaL________I_'��___ ._,Total length:__-••----�o--`.................. Seepage Pit: Distance to nearest well____ Distance4ro foundation___________________Distance to nearest lot line_____ v l Number of pits-------- I-----------Lining material----1 Ak-------size: Diameter------3.:..._ ----Depth------------2%•_ ___________• V" 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------------------------------------------ F-1 Distance to nearest lot line------------•------------------------------------•----------•--------------------- Remodelingand/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------ ---••- -•-•-------••-•-----------•------•--•---------------••---•------------•-------------•------•--••---------•------------- -------------•----------_-_--------------••-------•----------•----------------- ----•------•-----•-----------------------•--------------•--------•--••-•-•----------___---•----•--------------------•- -------------------------------------------------------------------------------------------= --•---------------------•-------------------------------------------------------------------_-_•----------------------------- 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)-------;� ------ho -------- ....... --------------------------------------------------------------------------------(Owner------------------------(Owner and/or Contractor) By:-----------------------------------------------•-----------------------------------------------------------------------------------(Title)---------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). a FO DEP TMENT USE ONLY APPLICATION ACCEPTED BY------ = ---------•-------••--------•--•-••-----------••- DATE...' / /--------- REVIEWEDBY------------------------------------ ----------------------------------------------------------------------- DATE............................................................ BUILDING PERMIT ISSUED-------------------------------------------------............-...................................... DATE----------------------------------- Alterations and/or recommendations:.................................................................................................-............................................................ er -------------------------------------------------- . --- - T f -`-----•------------ -•---•--•--•---•-••---•--- fL' - -------------------------------------------------- --------------- - FINAL INSPECTION - ---- ---- ---------- ----- ------------- Date....... ---------------------------------- ,r SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California rM-9 REV1690 9.69 F.P.CC.2M 6.60