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FOR OFFICE USE: L---------------------- / /- ___ ------------ , APPLICATION FOR SANITATION PERMIT Permit No. .; .1% __ .. ----------- -----14 - (Complete in Duplicate) - - - This Permit Expires 1 Year From Date Issued Date Issued /2s a9�19r.� Application is hereby made to the San Joaquin Local Health District for a permit to construk and install a work herein described. This application is made in compliance with County Ordinance No. 549./1 / JOB ADDRESS AND CATION_., `- _ �`` • : ----- _ ----------/S �. Owner's Name-------------- - - -- - i' f� !- s ' = ------------------ ------------------ -------------------- ---- Phone------------------------------------ Address �a2! -----------J—►------ ---- ----------------------------------------------------------------------------------------------------------------- Contractor's Name------------ ---t----_--------------------•-----------------------------------•------------------.•---------------------- Phone----------------------------------- Installation will serve: Residence° Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ _'__ Number of bedrooms 7---- Number of baths _/__ Lot size ------.____--_.._"--_-_".-___."_-_.______________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table�.bft. Character of soil to a depth of 3 eet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob ptkHardpan ❑ 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-________________Distance from foundation--------------------Material_______-_____ ❑ No. of compartments-------------------------Size-------- -------- --- -----Liquid depth----- ----------------CapacitY-------------- -------- Disposal Field: Distance from nearest well- ------_Distance from foundation-_.__. (______.Distance to nearest lot line.____cf__.__... Number of lines_____"__-�___.-_________.__Length of each line_---___-____ ____ Width of trench-----; C v-.--------------------- Type of filter material____-- ------Depth of filter material".------- e`��Total length----- ____________ . Seepa e Pit: Distance to nearest well___ _d�p______.Distance from foundation__-_"_�6_-___.Distance to nearest lot line__./_ll-_~ 6� Number of pits--------- .__.____Lining material--------- Diameter_..__-47_._y___Depth....... 5.-_________ (,J Cessp ol: 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-------------- - Remo g and/or pairing (describe :---- - = -------=---- f0/�- / c--- --- -------- -- --- �! ----- �------------- -- --- _ ---------- ------ � *' ----- -� j r ---• , ----------------------- ------------------------------------------------------------------------------------ I hereby certify thZ�,�ave prepare this a lication and that the work will P Pp be done in accordance with San Joaquin County � ordinances, State laws, and rules and regulations of Ih San Joaquin Local Health District. (Signed)----��,� -----------------_._ __Q_ ________________________________________._.-._-_____"___- (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). OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ --------------------------------------------------------------- DATE------- REVIEWED BY----- - .y "t'" -------------------------•---- ---------------------------------------------------------------- DATE------ ----------- BUILDING PERMIT ISSUED---------- -- --------------------------------- DATE - - ------------------------------------------------- ---- Alterations and/or recomm ndation�:_-_ / - - - ----------------- - =� -D- - -----a- +} �G ---------=F t oq----•----z0--- -------- o ^ ! re y - - ----`--4------ - re -� ------------------- ��---- - , f a 7`---------/, -----� ----�----- r FINAL INSPECTION BY:.- --------------------- Date------------- > = � - ----------------------------------- AN AQUIN 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.