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t-UKUi-H : USE: ----- ------------ ---------- -_--- APPLICATION FOR SANITATION PERMIT Permit No. -� --- -'-4 (Complete-in Duplicate) ' `- 1 This Permit Expires 1 Year From Date Issued ©ate Issued __./ � App ation is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This a lication is made in compliance.with County Ordinance No. 549. 01 /j �?o,3 471 JOB AD RESS AND LOCATION._ L- t-r- Owner's Narne � , one- Address--A o-- _ . Contractor's Name-----1i .g ;----_----_ -------- Phone Installation will serve: Residence ❑ Apartment House p Commercial ❑ Trailer Court ❑ Motel 0 Other ❑ Number of living units: _1._.._ Number of bedrooms --2-- Number of baths I_..._ Lot size Water Supply: Public system ❑ Community system ❑ Private,$ Depth to Water Table/-q_b_ ft Character of sail to a depth of 3 feet- Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe ❑ Hardpan ] Previous Application Made: (If yes,date,.__..........._ I No El Construction: Yes No ❑ FNA/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 I Disposal Field: Distance from nearest well./fit--------Distance from foundation-.�¢--- .._Distance to nearest lot line Z W°-.--- �3 .� Number of lines ------ ----- -------------------Length of each line--------/----------------Width of trench.._i�' _*-----,--- ' ----------------------- Type of filter material_ ____________Depth of filter material-__�_ '----_.__--Total length__/Q'a-------•---- •----------a' Seepage Pit: Distance to nearest well.... ❑ Number of pits__ ______Distance from foundation------------------- Distance to nearest lot line----------------- . ._--.._.. ..Lining material------.-___._ (- Size: Diameter Depth- ----------------- 6, Cesspool: Distance from nearest well ----------------Distance from foundation-------- t ------------ ...-Lining material----- ---------------------- ------ � � { ❑ Size: Diameter- -- --- ---------- - --------------Depth------ .................. ------------ --.Liquid Capacity----------------------------gals. Privy: Distance from nearest well------ ----- ------ --------Distance from nearest building ❑ Distance to nearest lot line---_-_ ------------------------_ Remodeling and/or repairing (describe):--- ----- ------------- - - ------------- --------------- ------------------------------- ----------------•------------------------ ---------------- ----------------- -----•----------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in-accordance with San Joaquin County e ordinances, State laws, and rules and" J Palafions of the San Joaquin Local Health District. (Signed).- Ul '" �_ �, 7�f/�--- _ ..- ----------- ----------- ----------- ----------------------------- -.(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"-- . -_ -- ---_-- - --------------------------------------------------- " DATE-- 7`/1_' -- ----------- .- -/_.__..."_.-- ---- - REVIEWED BY------ --------------------------------------- - - �� ------- � ----------- ---- ----------- - - DATE------------- -------------------- UILDING PERMIT ISSUED---------- --------------------------- Alterations ------- ----- -----------Alterations and/or recommendations:_..............__-----_ - ------------------------- - ------- --------------------------------- ----- - -------- - -------"----------------------------------------- --- R"At INSPECTION BY:- ,[ D ----- C ------------ ate__. . r SAN JOAQUIN LOCAL HEALTH DISTRICT ; 1601 E.Ma:elton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi, California Manteca,California E.H.92M 1-67 Vanguard Press Tracy,eolifornia