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FOR OFFICE USE: --------------------------------------------------------- ----------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. s .o --------------------------- - -- --- (Complete in Duplicate) This Permit Expires 1 Year From Date Issued bate Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. ,,.This a plication is,made in compliance with County Ordinance No. 549. t E. U,�S_F- t? f JOB ADDRESS AND LOCATION. - - �,.. . -------------------- ¢ r N7.f ----------------- ------------- -Q-c ' � �/� j - - - Owners Name !'_�-TI!..-._ +------ -----------_' �- ------------------ ---- ---- Phone---------------------------.---- AddressI--�o =1'74---fl:�' -- f -------------- ------------ ----- Contractor's Name i �a�srC�_ �tr.Lr Phone Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __0_-- Number of bedrooms Y -._ Number of baths f--____ Lot size --- a -______________________.__.-- Water Supply: Public system ❑ Community system ❑ Private [Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand E] Gravel F] Sandy Loam E] Clay Loam ❑ Clay dobe ❑ Hardpan ❑ 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--•--- ---------------- " Dispos field: Distance from nearest weft---t1'47-__..._.D�stance from foundation �Vii?__..__..Distance to nearest lot line___-�..-______ Number of lines------.------------------ --------Length of each line--------- ............Width of trench-------- --------------------.-iT .l Type of filter material------15;_R.........Depth of filter material------ _tl-_"____.Total length----4_a_-____________________________ i Seepa Pit: Distance to nearest well...__La0_1__-____Distance from foundation----f_°_._.___.Distance to nearest lot fine_ ---_.___.__ -__--_--Linin material_____.5-A.•______-Size: Diameter-_____.__ `�_-._.__Depth Number of pits----------1 g ? p ------- ------------ 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--------____----_-_-____.____..__..__..._. ❑ Distance to nearest lot line----------------------------------------------------------------------•----------------------------------------- 0 Remodeling and/or repairing (describe: ..------------ ------------------------------•-------------------------------------------------------------------- •�� ! !-.cl -------------------------------•-------•-----------------------------------= ------------------------------------------------------ -------------------------------------------------------------------------------- ------------------------------------------------------------- --------- ------------------------------------------------------------•-------:-----------•----------_----------------------------------------------------------------------------------------- --------------- ------------ I hereby certify that I have prepared this application and'that the work will be done in accordance with San Joaquin County �' M ordinances&Sflaws, and rules and regulations of the San Joaquin Local Health District.(Signed)----- --------- --- --- - ------- - ------------------------------------------------------------------------------------------------------- and/or Contractor--- `-------- -------=- ---- --------------------------------------------------------------------- --- By:-- (Title)---------------------------------------- (Plot - - (Plot plan, showing size of lot, location of stem in relation to wells, buildings, etc., can be placed on reverse side). �r FOR DEPARTMENT USE ONLY --------------- ------------ DATE__/,/_--�C}� APPLICATION ACCEPTED BY---; f 4/1 ---- REVIEWEDBY--------------------------------------------- ------------------------------------- -----------------------------------------• DATE------------------- BUILDING PERMIT ISSUED------------ ------------------------------- ---------------------------------------------- --------- DATE--- ------ Alterations and/or ---comm----dations----------------------- ----------- ---------------•--•-- ---------------------------------------•--- ------------------- . ---- ------------------------ . ----------------------------------------------------------•------•--------------------------------------------------------------------------------------------------------------------- -------------------------------- -------------------------------- ------------- ------ -- --------------------------------------------- ------------------- ----- -------- ---------------------------------------------------------------------------- ` ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---- ----------------- ---------- /�- /�'"� FINAL INSPECTION BY:- � �r.,� ----------------- bete ' - --------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.00. �� x I