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} FOR OFFICE USE: _ y' E ------------------------------ -- ---- APPLICATION FOR 'SANITATION PERMIT Permit No. f �� ----------------------- --- ------ ----------- -------- ------------- - ----------- (Complete in Duplicate) . I._- ... . -_................ This Permit Expires 1 Year From Date Issued 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 LNo. 549. JOB ADDRESS AND LOCATIO , __:QY .. -_------- ------------- -------------------------- I ,. ---- Phone---------------------- -- Owner's Name------ - �- - ------ -- - ------------------------- - --- ----------•------------- ----- ---- -- ---•--- ` �_____ __-_•------------------------------------•------.__--.___----_-__--__--__---- Address------------dr 7 - ----------- Contractor's Name------ ►�. Phone --•-------------------- ---------f----------------- ----------- -- Installation will serve: Residence [!( A artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ n Number of living units: ___ _-- Number of bedrooms _ Number of baths ` �_- ---- Lot size ---��-rx..� ---------------------- Water Supply: Public system ❑ Community system ❑ Private [Depth to Water Table __-..._- ft. Sand Gravel Sand Loam Clay Loam ❑ Clay Adobe❑ Hardpan ❑` Character of Boll to a depth of 3 feet. Sad ❑ ❑ y ❑ Y Previous Application Made: (If yes,date....................] No ❑ New Construction: Yes:❑.,,,FNor❑, FHA/VA!: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permittedifpu lic•'sd Dir isn vailable within 200 feet.) Septi c T nk: Distance from nearest 7a.......Distance from foundation--.fO`__-__-_-_.Material_. --------------------------------- d ---------------.-______�__-_-_-. ' No. of compartmenfs.---y---------------eSize�jFL./Y�_X.�.------Liquid depth---_-"�---.-------------Capacity---/-�p-------- - r- r � Dispos Field: Distance from nearest well_.-.Z�-----Distance from foundation___._ZQ._______.Distance to nearest lois line_ ____________ Number of lines------------- Length of each line------ZPO------_---_._-.Width of trench.--- __`_-______-____----.- Type of filter material--___ '�___--_--Depth of filter material__---__..fir___----.-Totallength_--_� --------------------------- 1 . Seepa e Pit: Distance to nearest well-.__-r J©4___--.-Distance from foundation----_/P-__--_-.Distance to nearest lot lme ._.__--_-- Number of pits----_..__----1�—--- --_Lining material-------- !Z t---Size; Diameter_______t�3_H.......Depth__k. ____..__ Cesspool: Distance from nearest well........-.___..Dista nce from foundation-----------------'-.Lining material...... _____ ..................... El Diameter.-- `° Depths _ -----------'i---------•-Liquid Capacity----=----------�------------gals. I Privy: Distance fronearesl-a m t wel :__`�`:---`I" . ------------------ from nearest building1 = Distance to nearest lot line = { - ---------- Remodelingand/or repairing (describe):--------------------------------------------------------3�----------------- ------------------•-------------------------k-------------------------------- ---- --------------------------------------------- ----------------------------------.-----------------------------------------...------ ----=------;t w-----•---------------------------------;-----'--------------- - - r - --------- -------------------------- ------------------------------------------------------------------------•---------------------,---;- --,--- -•---------------------------------------------- ------------------------------ I hereby certify th I have prepared this application and that the work will be done in accordance with SaFn Jodquin County ordinances, State laws, an rules and regulations of the San Joaquin Local Health District. -------------------------------- ran= R =Signed}v__= T" --- - -- -- - ---- (Title} ------ - - ------ ----. `_.d_./.ot'C-o--n--t-r- acfior}r_ BY: (Piot plan, showing size of lot, location of system in relatio to wells, buildings, etc., can be placed on reverse side). FOR DEP RTMENT USE ONLY p APPLICATION ACCEPTED BY ------------------------------------------------ DATE - "-/ - -------------- REVIEWEDBY-------------------------------- ------------- --------------------------- --------------------------------------- ---------- DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED-------- ---------------------------------------------------------------------------------- --------- DATE--------------------------------------- ---------------------- f Alterationsand/or recommendations:--------------------------------- -- ------- --------------.------------------------------------•-----------------------------•-----------•-----•--•---------- --------------------------------------------------------------------------------------------------------------------•----------------------------•--------------------------------------- •------------------------ ------------------------- ------ --- ------------------------------------------------------------------•----------------------------------------------------------------------------------------------------- ----------- -- --------------------------------------- -------•--------------- ----- -- ----------------------------------------------------------- -------------------------------------- ---------- ------------ ----- AD— k FINAL INSPECTION BY:. r^2 '' ------------ Date °"` .~�-------- ---- ---- - ---- ----------- i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Nazellon Ave, 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ` r.P.CO. y