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FOR OFFICE USE: 'f - - ' APPLICATION FOR SANITATION PERMIT Permit No. ..l ----------- +-------------- ----------------- (Complete in Duplicate) G r __------------------------------------------------- -, 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.#R -------- ----S� -- -------------------- -------- ------------ Owner's Name --- f� ----------- ------ --------- Phone7w-_ �t a �s r - Addresst14 ".. rl�� -: / {�_„ -_p '_1 -f?. ._. -------------r Contractor's Name --•------- ------- Al --- QIG1 - Phone.. . •--��__ Installation will serve: Residence ❑ Apartment House ❑ Commercial X Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms ________ Number of baths -------- Lot size _ _4---------------------------------- Water Supply:- Public system ❑ Community system ❑ Private X, Depth to Water Table 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: 7- (No etic tank or cess oolpermitted 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----------------------- al Field: Distance from nearest well.-/-6-01----Distance from foundation_--7------ r.Distance to nearest lot line___�l___ _ pispos Number of lines----------- __Length of each line__•-U.i_ _�0U__Width of trench..___'=___.__ '_ A Type of filter material_____ -�_Depth of filter material_-_f.!J-r_.__...---- otal length------- _____��7�7___ SeePit: Distance to nearest well----------------------Distance from foundation------------------- Distance to nearest lot line----------------- F_1 Seepage Number of pits----------------------Lining material----_------------------Size: Diameter----------------- ---Depth----------------------.---- ---- Cesspool: Distance from nearest well-----------------Distance from foundation____-----------.... Lining material,____--_._..-._.__-_._.__-_______.__.. n ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: A Distance from nearest well-----___-----------------------------------------Distance from nearest building----_-------- ------------------___----__. ❑ Distance to nearest lot I;ne------------------------- --- ------------ --- ----------------------------- ---------------- ----------------- --------------------------- Remodeling and/or repairs {describe):____- -- -.......... �------- _------_-` --- _____._ trfic ------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------•-------------------- -------------- ------------------------- ---------- -- 1 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)---------------------------------------- IQ-k ft.i!�.�.a------------------------------ Owner and/or Contractor (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-.-- _--`__-!- -Q`- ---- -- --------- ---------------------------------------- DATE---------C%--7L ._.6-a'a------------------------ REVIEWEDBY---------------------------------------------"----- --------------------------- ----------------------------------•---------- DATE------------------------- ---------•----------------------- BUILDINGPERMIT ISSUED------------------------------------------------------ -•--------------------------------------------- DATE-------- ---------------- ------"------------------------- Alterations and/or recommendations:----------- ------------- --------------•-------------------------------------------------------------------------•------------------------------- -•---------------------------- ---------- --------------------------------------- --------------- ---------------------------------------------•---------------•----------------------------------•------------------. ---------- ---------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------- ----- -- ----------------- - -- - --------------------------------------------•------------------------------------------------------------------------- Y '. ______________________________________ _______ _ __pfA�-- -- FINAL INSPECTI ------------------- ---- ----- Date _�O ` fir SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.C C.