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FOR OFFICE USE: --------------------a .�o- -- APPLICATION FOR---SANITATION PERMIT Permit No. .�� 11�. ------------------------------------------ ---- ---- "- (Complete in Duplicate) .---_._ 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. T pplicationris-made*in-com Dien ec gwith County Ordinance No. 549. [43 &b—31 JOB ADDRESS AND LOCATION-______..... ...___lf!__-___-- _ -7 - --------------- '�✓- Owner's Name l�! ------------------•----------•----- ---------------- Phone---- -----� Address---- .9 Z44Contractor's Name---- S 7� ---------------- Phone--.---------------------....-- --- Installation will serve: Residence 0 Apartment House ❑ Commercial Mailer Court [E Motel E] Other ❑ Number of living units: -------- Number of bedrooms _ Number of baths Z__ Lot size -V'__ „P :--_-_-_----:----_._-._-_ i" Water Supply: Public system ❑ Community system ❑ Private P?-'I5epth to Water Table -M-ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑' Clay ❑ Adobe'❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No 12�New Constructibn. Yes [T'—N—o ❑ FHA/VA: Yes ❑ No [ �' TYPE OF INSTALLATION AND SPECIFICATIONS: i, r (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance fronearest well. a.� m ...Distance from foundation_�O--- ----------Material-----(--P---- .- --- No. of com artments_ Size--- : X_` Liquid de th-----� - ----------- ------ �"---- Ca aci ------- Disposal Field: Distance from nearest well_•S`�_------Distance from foundation,/b__�----------.Distance to nearest lot line--S__------. T e of filter materiai'�O-L, _ Depth of filter material_-18-_`_'___________-Total length Number of lines-.- .`__.._ . _ ---'-Length g F p .................Len th of each line._c�'�..__________.____-__Width of trench_____. '�__..____.._ YP - �1 P 9 , Seepage Pit: Distance to nearest well....-.__-_.__----.__Distance from foundation--_---___-----.---.Distance to nearest lot line-------- ---------� ❑ Number of pits----------------------Lining material-----------------------Size: Diameter--------------- -- --Depth----...-------------- ---------- Cesspool: ------ Cesspool: Distance from nearest well---------------"-Distance from foundation---.------------- _.Lining . ------------------ -. material-------------------------- _--___.' Diameter--------------------------------------De--t ------------- Liquid Capacity --- gals, ❑ Privy- Dslance fromnearest well.-..____"-_....-_-_ - -- ----------------------Distance from nearest building----------------------------------------- El .--..---___ ❑ Distance to nearest lot line-------------- -.----------------------------- �.: -- "------------------------------------------------------------------------I----------- ' - r Remodeling and/or repairing (describe):---- ------ -- ----------------- -----------------•------------------------------------------•--------- ------------------- ------------- --------• � --------------------------"_"-.----_..-----.____.___.___----___-.--___-_-..._______.___._____... .._"______________________________________________"-.----"-____.--__----------..-.._-_-_-_.-_--.---."_"--_"--.-_-_---_---_-----____--_____------_.-_---_-_----_.-----_------_-..-_-----_--__._---"-"------------- ____________"_-_-_.-..--.-_-_.-..--_.-_"----_.--_.-----_-_-----___-_-_--------__-_-__--_---_-----------.-_ ... `1 N I hereby certify that I have prepared-this application and that the work will be done in accordance with San Joaquin County i t ordinances, State jAs,.and rules regulati ns of the San Joaquin local Health District. (Signed)------------ - --------------------- ---------- - ---------------------------------------------------------------------------------------------------------(Owner and/or Contractor) I 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 f t APPLICATION ACCEPTED BY---Lit. __1C----------------------------------- ---------------------------------------- DATE----- .... REVIEWEDBY---------------- ---------- ------ --- - ----------------------------------- ------------------------------------------ DATE--------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------ ----------------------------- ----------------- DATE-------------------------------------------------------------- Alterations and/or recommendations---------------------------------------- -----------------------------------------------•-------------------------------------- *---------------- ------------------------------- -----------------------------------------------" ------------- ------------ -------------------------------•---------------------------------------------------------------------------- ---- ------ --------------- -------------------------------------------------------------- -------------------------------------------------------- ---------------------------------------I-------------------------- ------------------------------------ "------------- --.--------------------------------------------------- ------------------------------------------------------------ ------------ - ---------- -------- ----------------- FINAL INSPECTION BY:-- - -------------------------- -------------------- Date- --------- a ' 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. -