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FOR OFFICE USE: --------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ---------------- --------------------------- - - ------ _ __ __1 _ �----------- (Complete in Duplicate) ---------------------- Date Issued i___ ---------- This Permit Expires I Year From Date Issued Applic4fion 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 LOCATION...... I Owner's Name-------------- --------------------------------------------------------------------------------- ----- ------------------------------------- ------ Phone_ ------ 11� -644---------------------------------------------------------------- Address--_--------_-------............... i---------- ------- Contractor's Name------------------------------------8 W. Phone. Installation will serve: Residence ElApartment House E] Commercial [] Trailer' I Court E] Motel Other 0 a _--__'53- 1 23_21)----------- Number of living units: --I---- Number of bedrooms Number of baths -----L Lot size .__,xa 'Supply: Public system F ft. Other r I Water ] Community system [I Private Er'Depth to Water Table Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam El Clay Loam [I Clay F] Adobe[] Hardpan R_ Previous Application Made: (if yes,date--------- - ------- ) No F7l New Construction: Yes [] No E] FHA/VA: Yes El No El TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public I sewer is available within 200 feet.)/ Septic Tank: Distance from nearest well ------Distar irom win �a n Materi1..____._____.____--------------- --------- ...�ce if d 10----------- - - - Size�ll iquid deNr No. of compartments-.- - -----Capacity..19--. h Distance to nearest lot line---�G ------- - Dis ----Distance from foundation--- ------f------ ield: Distance from nearestell---. p;*1 Number of lines_______.__ - ------ -Length of each line------ - -----*Width of trench----- I------------------------- _-,,�_kjR_Depfh of filter material------ IT Total len ------- 100---------- Type of filter malreriai- i ----r----- gth-7-' See it:,� Distance to nearest well____ --Distance fpr f riclation----149---------Distance to nearest lot line______--------- Number of pits____��.---- --Lining materialAmr-RI.Size: Diameter__--5- 1-1----Depth------- ----57 ------- 79 /ro"m-foundation----------------- -�Li 1-1 1 --------- VA Cesspool: Distance from nearest well_____._------.Distance Lining materi4---------------------------- 0 Y� gals. Size: Diameter-.-- -------------- --------------- epth--------------- ------------- ---------------------Liquid .--gals. Privy: Distance from nearest well_____-- __----------------------- --- _Distance from nearest building-------------------------- ElDistance to nearest lot line-__-___ --------------- ------ ---------- ------------------------------------------------------------------------------------------------ Remodeling and/or repairing (describe):-.-_.--------- ------------�-.................---------------------------- -------- -------------------------------------------------- ----------------------------------------------------------- ------------------------------------------------------------ .......------------------------------------ -------------- ------------------------------- - . ---., '!t-------------- ----------------- ---------------------------------------------------------------I----------------------------- ---- ---------- ---------------I----------------------------------------------------------- - ----------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------__------------ ------------- I hereby certify that I have prepared this application and that the work will be done in accordance with Son Joaquin County ordihances, State laws, and rules and regulations of the San Joaquin Local Health District. (Owner Jand?or Contractor) (Signed).-A------------�4. --------- -------/2%%'2 „_---- --- ------ ---------- T ----------------------------------------- By:---------------_I------------------------i------------------_---------------------- -_-(Title)---------- -------------------- ---------- --- ---- -------- (Plot plan, showing size of1at-location of system in relation to wells, buildings, etc., can be placed on reverse Ode) FOR DEPARTMENT USE ONLY ------------- DATE----- -------------------------- APPLICATION *CCEPTEDl BY.-------- ------------- ---- ------------------------------ ----------- -- - - --------------- DATE------------ ---------------------------- REVIE -----------------------_------------------------------------- -- --------- WED BY--- -------- BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE-----------11---------------------------------------------- Alterations and/or recommendations----------------------------------_.----.------- -------------------------------- ----------------------------------------------------------------------------11-------------------------------- ------------------- ---------------------------------------------- ------ ------------------- ---- ---I------------ --------------------------- --------------------------- ------ --------------------------------- --- ---------------------------- -----------I- ------------------- -------------------------- ----------------------------------------------*--------------------------------------------------------------*-----------------------------------*----------------------------------------- ------ ------------------------- ----------------------I----- ------------- ---------------- ... ..... --------------- ---------------------------------------------------- ----------- ----------- ----------.......... FINAL INSPECTION BY: Date-w;�-Y.- ------------------------ --------------- ------ �----------------- ------ - 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.CO.