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FOR OFFICE USE: --------------r r a . ---------------------------- ----------------------- APPLICATION FOR SANITATION PERMIT Permit No, c /✓� ----------------- (Complete in Duplicate) '" J This Permit Expires 1 Year.From Date Issued bate Issued �1_-_ - � ------ --fes-�- ----------------------- 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 LOCATION -l'°�-----'------------`�-"`=--�---------- - Owner's Name--- ------ _.Rik.G!'ti�-•--------------- -------------•------------------s--- -= ------------------------------------------ Phone----------------------------------- :. Address_____-____ _ . • ... ---•--------------------------- Contractor's Name .. `� -------••-----------:-----------------------------•- ---------------------------------------------- Phone...,:------------------------------ Installation will serve: Residence [Apartment House ❑ _Commercial ❑ Trailer Court' ❑- Motel ❑ Other ❑ Number of living units: __I___ Number of bedrooms , _:_ Number of baths _/----- Lot'.size __8 ---------._____________________________________ Water Supply: Public system Rr Community system ❑ Private E] Depth to Water Table _p 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 ❑ 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 9 i Disposal Fiel�. Distance from nearest welf------------------Distance from foundation--------------------Distance to nearest lot line----------------- ❑�' Number of lines-----------------------------------Length of each line------------------------------Width of trench.---------------------------------- Type of filter material-------------- Depth of filter material-_____________---------Total length-------_---------- ------------------------- Seepa it; Distance to nearest _._.._____Dis once f om undation_/ _�__.________.Distance to nearest lot line_�`��__._____ I {Number of pits.------1-------------Lining aterial___"J Lk-- ----Size: Diameter____-,3.3--- -----Depth---------•Zig--..____--------- Cesspool: Distance from nearest well--------------___Distance fr oundation----------------___Lining material_.-.-__-....____._..__._________..__. ❑ Size: Diameter--------------------------------------Dep -----------------------------------------------------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 ordinances, State laws, and ru and'regul�ofn Joaquin Local Health District. (Signed)-------------• -------=-- ---- •�------------- --- -------------------------------------------------{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). rt FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ l' -- --- ---------- ----------------------------------------------- DATE------ REVIEWEDBY----- --------------------------------------- '-- -- - ----------------------------------------------------------- DATE BUILDINGPERMIT ISSUED__,-'i--------------------------- ---- -------------------------------------------------------------- DATE------ -------=-------------------- ----------------------- Alterations and/or recommendations:------- ---------------------I- -------------------------------------------------------------------------------------------------------- ----------------------------------------------------------•------------------ - --------------------------- -------------------------------- ----------------------------------------------------------------------------- ----------- ------ ---------------------------------------------------------------------------- ---- -•---------------------•-•---------------- ------------- -------------------- -- ----------------- ........ FINAL INSPECTION BY---------- ------------------ SAN-JOAQUIN --- - SAN-JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h street Stockton,California Lodi,California Manteca,California Tracy,California F.P.r O. E ' I