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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ........................ --------------------------------------------------------- ---------------------------- ---------------------------- (Complete in Duplicate) ��z --------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued ../ /.- .. U 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. 54 . JOB ADDRESS AND L A ON •---•-/ "��--- --------............................................................--•---•-----••----• Owner's Name ( . �Xa Phone. Address -- .._.....--•-----------------------------•-•. Contractor's Name------------ Phone ....:. ----•------•----- Installation will serve: Residence gp-1partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---/-- Number of bedrooms ._A. Number of baths Z. Lot size _..�Qf ---141&........................... Water Supply: Public system [Community system ❑ Private Ap ❑ Depth to Water Table _;Kpt 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 EK—New Construction: Yes ❑ No Z?'*'_FHA/VA: Yes ❑ No 9-- 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--------------------------------_---------------- r � No. of compartments Size Liquid dept Capacity Disposal Field: Distance from nearest well-------- _-_--_Distance from ,founclation.:_ Distance to nearest lot line.................i _--.Width of trench...................... Number of lines--------/_�'-___.yy___--__.Length of each line__-_��._:=�� .__-... Type of filter material b�_ epth of filter material-_--._1�-- ..._Total length-------'y........................... Seepage Pit: Distance to nearest well--------'-----_---_Distance fr m fo ndation.__.�m-._..Distance to nearest lot line.,��.. C4 [� Number of pits-------/-----------Lining material.. 040C__-Size: Diameter-----------------Depth_,- ............. Cesspool: Distance from nearest well-----------------Distance from foundation....................Lining material...................................... CA ❑ 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)------- _1409//11 _J----- fi r -' ........................................................ --------------------------------------------------------------------------------------------------------------------------------------------!; -------------------------------------------------------------------------- ----------------------•---------------------------------•----------------------•---------•-••---------•-••----•--------•---•-•--•---•-----•----•-------•-------------•-•------------------...•--••--•----•---•-------------... -------------------------------------------------------------------------------•--------------------------------•---------------------------------------------.-..------------------------------------------------------------ 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 and regulations of the San Joaquin Local Health District. (Signed)----------------- ;-ge--------- - - - -- --------------------- - --------------------------------------------------------------(G*wwwmWy6mr Contractor) By:------------------------------------------------- .o/1tJ� ...................-----------------(Title)------. ----------- (Plot plan, showing size of lot, locati f system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------- ----- ---- DATE.....l_Z-. ?- --..... ._EC_ ............... REVIEWED BY----------------------------------- - ---- - ----------------------------------------------------------• DATE............................................................ BUILDINGPERMIT ISSUED.............................................................._...................................... DATE............................................................. Alterations and/or recommendations:--------------------------------------------- -------------------------------------------------------------------------------------------------------...................................................................................................................... ----------------------------------- -------------------------------------------------------------------------------------------------------------------------•-----------------------------------------------•--_------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------•-----•------------------------- ............................. ---------------------------------------- ---------------------------------- ------------------- ---------------------------------------------------------------------------------------------------------•-•-•---------------- n FINAL INSPECTION BY:.---GV ------------------------------- Date---- ------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Streit 424 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES-9 REVISED 2.59 F.P.DD.2M 6.60