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OR OFFICE USE: f 3 G ------------_____-..---.---�------------ ------------- APPLICATION FOR SANITATION PERMIT Permit No. . . ....... I, -------------- (Complete in Duplicate) �f 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. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND L CATION----- l-3 Owner's Name----- -- - ='�/�.---- --- --•-. - ----- --------------------- ----------------- ----------------- ------ --------- Phone-. -- � -------------------•-••-------•--- ��f/// Address------ -�-��.�=--------------- -------------------V --•----------- --- -•-- ----------- --- -------- „-----....-------------• - -- - Contractor's Name ----� ? .--- , Phone_ ...--7� `f'•41 Installation will serve: Residence Apartment House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _-.�-.- Number of bedrooms - - Number of baths --1---- Lot size ------ ---------_--------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Wafer Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel Ej Sandy Loam ❑ Clay Loam Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date-------- ----------) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ,r (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-TO-------Distance_from fo .n anon-----/_0------.Material..:----.4`�(______________________ [ No. of compartments---------_- Z---------Size----- -Liquid depth_--,0___1�--------------Capacity---16-_ ----- Disposal Field: Disfance from nearest well --11-19.--- -Distance from foundation----e C?--------Distance to nearest lot line--- ",__------ :s :. K Number of lines----__---- .._--_ *� .-Length of each line_- 6-,----------------Width of trench--..--; - `_1 ----_----- 11 A�ah9 Type of filter material----- f ;'�} IT---Depth of filter-material-------1-$.-.._,____Total length---.--1.-1--Q---........................ Seepage Pitt) Distance to nearest e[1-----I4�_------Distance from foun afion-_-/-0_-_--.--.Distance to nearest lot line_..---.--.-.-.• 1 Number of pits---___ ../-----Lining material-----_Size: Diameter---__. %_1_._---...Depth_' -------fl Cesspool: Distance from nearest well--.-- -_----_Distance from foundation--------------------Lining material--.-.-._..---_----------._-------.-. 0 ❑ Size: Diameter------------- ------------------------Depth--------r------------------------:.---------- ------Liquid Capacity----------------------------gals. - ❑ Distance to nearest lot line------------4---------- - (� I Privy: Distance from nearest well--------------------------------------------- ...-Di Distance from nearest building__-`_---'.-----'-----.---- ------------ + ' { Remodeling and/or repairing (describe):----- -------- ------------------------ ------------------------..............---------------------------------------------------- --------------- ----------------------------------------------------------- -------------------------------------- � i ----------------------------------------------------=-----------------•------------ ----------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------- --------------- ------- 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 rules an regulations of t San Joaquin Local Health District. n (Signed) ------- ---- (Owner and/or Contractor) ---------------------- ------------- x z.1 By:------- ------------------------------------•--------------------------------------------- --------------------------------------- ------------ ----------"----=----------(Title)--------------------------------------- - - - ----------- (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc.;'can be placed on reverse side). FOR DEPARTMENT USE'ONLY 3. 1 DATE = f ---- ---------•------------------- qq REVIEWED I BY. ACCEPTED BY = = DATE �f BUILDING PERMIT ISSUED----------------------------------1—%j f---- ------ DATE-------------------- - � Alterations and/or recommendations-----------------------------I----------------' L--=-------------------•---------------------=-------, ----------------------- --------- --------------------------- --------------------------------------------•------------- -----•---- ----- - ------------------------------------7-•------------------- --------------------- -- ------------------------ ---------------------,--------- - ------ ------------....-• -- ----------------------- ---- -------------------- ----------------- ------. i E FINAL INSPECTION BY:----.0---'------ -- ---- --------- Date......... - b `- SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E.Haxellon Avtr. 300 West Oak Street 124S ore Street 205 11VesT 91h Street Stockton,California Lodi,California Manteca,California eTiacq,California