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FOR OFFICE USE: =1 ---------------------= ---- APPLICATION FOR SANITATION PERMIT Permit No. _G .-- -------------- -----4-17 -1-1---------------------- (Complete in Duplicate) f- ------------------ --- 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 LO ATIO ---3 .1_, ----- AX -- ---------------------------------------------------------------------------------------------------------------------------- Owner's Name-- ------------------A �•� - - Phone Address------ ° -- ---- ---- t- 4�w., /' .r�.ism Contractor's Name----- ..ca . ---------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence N( Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: A----- Number of bedrooms -_X_ Number of baths _`----- Lot size ___-k�_X---- _________________________ Water Supply: Public system X Community system ❑ Private ❑ Depth to Water Table _Wft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam F] Clay Loam ElClay El ,AdobeHardpan ❑ Previous Application Made: (If yes,date_5/X1-166) No ❑ New Construction: Yes P( 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_NroNi=•__Distance from foundation----- i---------Material-__-�� No. of compartments..__--_ ------------Siz0V—CXu_k__S-_. __Liquid depth----- - ---------Capacity__.V -------- W i o Disposal Field: Distance from nearest well-_NaNE_Distance from foundation....10_�-___._.Distance to nearest lot y�line----------------- ` IX Number of lines-------�q�_OL_------- _-_- Length of each line_9b.__f__7.0__--___.Width of trench..._-. ._i-- c�----------------- Type of filter material___ -___________-Depth of filter material---------1911------ otal length----------------------------------__-___ Seepage Pit: Distance to nearest well----------------------Distance from foundation---------------------Distance to nearest lot line_____.______-._ ❑ Number of pits----------------------Lining material----------------------_Size: Diameter-----------------------Dept h--___--_-_--_-__--____-___--._ 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--_-__-_____________--__-_--__-__-_- (1w ❑ Distance to nearest lot line - ---------------------------------------------- Remodelingand/or repairing (describe):---------------------------------------------•-----------•----------------------------•------------------------•--------•------------------------------- ------- ------- - --------- —, 6 — V+N v ------- ------------------------------------------------------- ----------------------------------------------------------------•----- --------------------------------------•---- ------------------------------ 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 r e andre u ons of the San Joaquin Local Health District. (Signed) - - -- - -- ------------------------------ ---------- ------------------------- -- -(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). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- X - -- ---------------------------- --------------------------------------- DATE--- a � REVIEWED BY. - --------------------------------------- ---------------------------------------- DATE------ BUILDINGPERMIT ISSUED------------------ ---------------------------------------------------------------------------------- DATE. - - Alterations and/or recommendations------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------- -------------------------- -----------------------------I -------------------- ------------------------------------- ----------- ----------------------------•------------------------------------ ------------- ---------------------- --- -----------------------------------------------:---------------- ------------------------------------------------------------ ---------------------------------------- -------- ��i v FINAL INSPECTION BY:---- ` ' --- -- --- ---- Date-------------- 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.