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FOR OFFICE USE, / APPLICATION FOR SANITATION PERMIT Permit No. . ------------------ --- - - ----- ---- -- -- -- (Complete in Duplicate) .,.,10 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 County No. 549. JOB ADDRESS AND LOCATION _ .?`. ----------•----- f� -------ptl/-------------------------------------------------------------- Owner's Name-1_ ------------- --------------------------------------------------------------- --------------------------------------- Phone.................................... Address._...X�)�x�^.. ....----- -------------------•-----------------------------------•••-•......----•--- •...... Contractor's Name--------- ••. --•-............. ...TA--------------------------------------------- -------------------------------------•--- Phone.............-..................... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel 0 Other ❑ Number of living units: ---I---- Number of bedrooms __3__ Number of baths __,02 Lot size ...................................... Water Supply: Public system ❑ Community system ❑ Private E�-tiepth to Water Table A- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [B_lay Loam ❑ Clay n 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.) j Septic nk: ' Distance from nearest well-----------------Distance from foundation--------------------Material.----_-_-__--.-.-_-_-___-.------------_-__---___. K1*1i No. of compartments--------------------------Size--------------------------------Liquid depth---------- ---------------Capacity----------------------- Disp sal Fiel Distance from nearest well__�A1D_.`_._Distance from foundation._J.3P..........Distance to nearest lot line.S_�...... Number of lines --------------- -----Length of each line- ,6--� -------Width of french----&'fr,*-------- --------- Q��,, Type of filter material.__?D__4-_J.._._Depth of filter material-----,1f__----------Total length----- Q_.-________________________ Sserage Pit: Distance to nearest welly---------------Distance from foundation34. ...........Distance to nearest lot line----r......... ❑ Number of pits----- ---------------Lining materiaL,__f?_ _itG1t-_.__Size: Diameter_'1kr--------.Depth_._-M__*:L:Z___...... 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-----------------------------._.-_--_--.-. ❑ Distance to nearest lot line-----------------------•---------------•--------•----------------------------------•---------- ---------•------------------------------------ Remodeling and/or repairing (describe):-------------------------------------- -------•-----•-------------------•-------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------ ------------------------------------------------------------------------------------------------------------•----•--•-------•---•-----------•------------------------•-------------------------------- I hereby certify that I have prepared this applicat' n and that the work will be done in accordance with San Joaquin County ordinances, State laws, an rules and re a ' ns of San Joaquin Local Health District. -______-_Owner and/or Contractor (Signed)•---•--••....•--... - By:------------------------------------------------------------------------------------------------------------------------------------(rifle)---------- ------------ ------------.. (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FQR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- ----------------- ---------------------------------- DATE-----/-.//:710-------------- -------------- REVIEWED BY--------------------------------------------•-------------------------------------------------------------- ------------------ DATE------------ ---------- -------------------------------- BUILDINGPERMIT ISSUED----------------------------------------- -------•--------------------------------------- DATE-------------------------------------------------------•---- ` Alterations and/or recommendations----------------------------------------------- ----------------------------------•-•-----------•---••--------------------------------------------------------• ........................---------------- ------------------------------------------------ ------- ------...................----------------------•---•-•-•••••-•---...--•---•-•------•---•------•---••-•---•--•-------... -----------------------------------------------------------------------------------------------------------------------_---------------------------------------•----------------------. ---------------------- --------------------------------------------------------------------------- ------------------------------------------------------------------------ --------------------------------------------------- ---._._--------------------------------------------------------------- ---------------------- ----------• - -------------------------------------------------------------------------------•-------------------------------------------- --------•-------------------------------------------- FINAL INSPECTION BY:--f�.!�i��''�'.?^',,�'-L��G��10�--------------------- Date.---------/-----'"--!f-- ---- - - - 't� --._...----------------------------------------....... 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.C C.