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F ROFF '_ICE USE: --- .n -- -------- --- ------ ' --- ------ ______._________ ______ ________________________________ APPLICATION FOR SANITATION PERMIT Permit No. ... _ - (Complete in Duplicate) -- 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 'No. 549. JOB ADDRESS AND LOCATION------------ X. f�'f Owner's Name------------- ---------- f1l Q--IV--------------------- - ---------------------------- ---- -------- Phone------------------------------------ Contractor's Name________________` -' I,S' ' /C' ---------•--------••---------- Phone--------_-------------------- - Installation will serve: Residence ❑'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number"of living units: _1__ Number of bedrooms __"Number of baths _/___ Lot size ---Ida ,'P_l?___.____.._____________________ Water Supply: Public system M--c-ommunity system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ©-<Iay ❑ Adobe E] Hardpan ❑ r Previous Application Made: (If yes,date....................) No B`ffew Construction: Yes ❑ No ❑ 'FHA/VA: Yes ❑ No E3--- 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----------------------- Disposal Wield; Distance from nearest well--------------._Distance from foundation.��_ T ____.Distance to nearest lot line-Z�_.�... Number of lines--------F1__________ ____________Length of each line__.," - ..Width of french___� _1��__..__________._ p Type of filler material__ 619<__Depth of filter material__ _`_--_-.-__..Total length______ --�___________________._ rrrv.. Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------Distance to nearest lot line_______________ ❑ Number of pits--------------_____---Lining material----------_---_--------Size: Diameter--------- ------- - ---Depth------ ----------- - ------------ Cesspool: Distance from nearest well-----------------Distance from foundation------------------..Lining material-_._._____---_--____.__._______..__. ❑ Size: Diameter----------------------- .........Dept h------------------------------ ---------------------Liquid Capacity----------------------------ga Privy: Disfahce from nearest well-------------------------------------------------Distance from nearest building.-_._._.__________._____-_.-_- R. ❑ Distance to nearest lot line------------ ---f ------ - ----------------------------------------------------------------------•------------------- Remodeling and/or repairing (describe):------ 7V ___.e---------- -----��---Xl_,5�_�ll�-�------� ---•------------------------- ----------------------------------------------------------------------------------------------------- ----------------------------------------------------- ------------------------------------------------------ ------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State lew , d rules and regulations of the San Joaquin Local Health District. (Signed)- -1----------------------- ---------------------------------------- ---- weer /or Contractor) I --------------(Title) �r By: --------- (Plot plan, showing size of iot, location cyrsysfem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_.._.. L .-</--------------------------------------------------------------------------- DATE----- -------------------- . /.. (�' REVIEWEDBY--------------------------------------------- --------------------------------------------------------- --------------------- DATE----------------------------- ----------------------------- BUILDINGPERMIT ISSUED-----------------------•---------------------------------------------------------------------------._ DATE.-------- ---------------------------- -------------------- . Alterations and/or recornmendations:-- ---- -- ------ - -------------- ------------ ----------------------------------------------------------------••-•--------•--- -•------------------- ----------------------------------------------------------------------------------------------------------------------------------------•-------------------------I------------------------------------ ---------------------------------- ------------------------------------------ ---------- ------------------------------------------------------------------ --------------------•--------------------------------------- ------------------------- ---------- ---- t ----- -- ---- -------- ------------------ - d � FINAL INSPECTION BY:. --------------------- -- Date - -" � 6— h SAN JOAQUIN LOCAL HEALTH DISTRICT 1641 E.Haxellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca, California Tracy,California F;p,CC.