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FOR OFFICE USE: - ----------------------- --------------------- � J ------------------ APPLICATION FOR SANITATION PERMIT Permit No. _........ _ ----------------------------- - - (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. e t JOB ADDRESS AND �LOCATION ��-�------` �------- Owner's Name----------------C17"111 I Phone Address-- `` ''' ...- ----- - ----- ------- -------------------------------------------- -------- ------ ---------- Contractor's Name----- u... ----• ----------------------------- Phone /'5/�'" Installation will serve: Residence [DApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 1 Number of living units: __r'r_-- Number of bedrooms _3-_- Number of baths __/_ Lot size --- ___R. _ _ .D_`--------t�_____-_ r Water Supply: Public system 91,110Community system ❑ Private ❑ Depth to Water Table _4�0 ft. y Character of soil to a depth of 3'feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 1]�Hardpan ❑ i Previous Application Made: (If yes,date__._ -_ --------) No ❑ New Construction: Yes ❑ No rHA/VA: Yes ❑ No ❑ ! t TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 04p �,Tank: Distance from nearest well ___ __Distance from foundation--------------------Material ----------------------------------------------- No. .-_ ___ -_ -.__ __--__._ ___. No. of compartments__----------.------------Size--------------------------_---Liquid depth--------------------------Capacity------.---------------- /Disposal . _ _-_- Disposal Field: Distance from nearest well Distance from foundation-__ __ :;5:Distance to nearest lot line_-- --.--- Number of lines...... _.________-------------- ___________ Length of each line___9'_e5)_____---s.---.Width of trench------- _______-;_---- Type of filter material.-- '�_r'CQ.=_Depth of filter material____ ----Total length------------------------ --_--.-6 Seepage Pit: Distance to nearest ell _-Distance�f m foundation_- G!-_-f.--.Distance to nearest lot Fine W Lel �° -- Number of pits_ _---------------Lining' mate ria l__ 4�.�.1�-''___Size: Diameter- _3>3 _____A#Depth____...__.. �� ___._ �. Cesspool: Distance from nearest well_________________Distance from=foundation____-_-.______._.Lining material-.__-_-__.___._____.______-_.__-----. ❑ V" Size: Diameter_-------------------------------------Depth---------------------------------- -- ----.__---Liquid Capacity----------------------------9als. � _____Distance from nearest building 'r Privy: Distance from nearest well-_-------------------------------------, --- - 9---------------------------------------- 110 ❑ Distance to nearest lot line I � ------------------------ --.------------------------------------- ------------------------------------------------- Remodelin9 and/or repairing describe) ` T'.. . ` ,f ------- - _ . P - S .. _____________---------------------_------------------_-----------------------------------------_--------------------------______________`____.__F- --___-----____-_-_______--.-___-____._....__..__._.__._._.____._ --------- Jr I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances,rSfto laws, and rule and regulations of the San Joaquin Local Health District. (Signed) � ms --------------------------------------------------- (Owns and/or Contractor) 1 i g ---- (Title)y:------------------ �'` (Plot plan, showing size of lot, location of system in relati�rjfo wells, buildings, etc., can be placed an reverse side). FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY `� DATE------- ^ '-'�- --- --- REVIEWEDBY-------------------------------------- -- - - -------------------------------- DATE-------- ------------------------------------------------ 'f' BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------- ------------------ DATE----- ----------------------------- ------------------------- Alterationsand/or recommendations:---------------- ----------- ----------------------------------------------------------•---------------------------------------- -----•------------ ------------- -------------------------•------------------- ------- ----------------- -----•------------------------------------------- -------------------- ------------------------------------ ------i%--------------- --------------- -------- ---- FINALINSPECTION 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