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FOR OFFICE USE:, t r 57 ------------------ - -- _______________________ APPLICATION FOR SANITATION PERMIT Permit No. . .........._.......... -- - (Complete in Duplicate) Date Issued ---------------------------------------_________.___ This Permit Expires 1 Year From 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 ANDL� 10 .."' - ''' '`------------ ----------------------------------------- Owner's Name fL ---------------------------- Phone Address -�---. , �/t9. ,8 A-----------------------111_ k / ----------------------------------------------------------------------------------------------- Contractor's Name--- ------------------------------------------------------- -•----------------------•-----•------------------••-------• -------------- Phone................................... Installation will serve: Residence a' Apartment House [Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _2-- Number of bedrooms _-�Number of baths> -_ Lot sizeQQ<7__g__-____-- -___________________ Water Supply: Public system ❑ Community system ❑ Private �epth to Water Table �rn_ 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 f�r"'F New Construction: Yes ❑ No e`_F_HA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: No septi Aor cesspool permitted if public sewer is available within 200 feet.) Sept ank- bistance from nearest well_________________Distance from foundation-----__..--________-Material_______________-______-________-_______-_-______- No. of compartments-------------------------Size--------------------------------Liquid depth--------------------- ----Capacity••------------ Disposal Fi d:J Distance from nearest well- ___Q__._Distance from foundation./j---_----------Distance to nearest lot line-__-____- ❑ Number of lines------- __�-_.-_-,�________________Length of each line__�.,�'-________-_.Width of trench.____`____�i_l_- ``_._.__-_____--_ vJ Type of filter material____.�_�_Q_w~*-___Depth of filter material____,/f�'_`'.______Total length_-____7%.:5-___'_________..______.__ 0) 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--------------.---------------------- El Size: Diameter--------------------------------------Depth-------------------------------------- -_ _____-Liquid Capacity gals. Privy: Distance from nearest well -.---------------------------------------------Distance from nearest building______________________________-__.__.__. ❑ Distance to nearest lot line-------------------------------------------------------------------- ------------------------------------------------------------- S Remodelingand/or repairing (describe):------------------------------------------------------------------------------------------------ --------------•----•---------------------------•-------- ------------------------------------------------------------------- ►T�'-----� N€Rs----- &-------�a i 8�_��T CRs 9. - ----------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------ --------------- 9 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------I------------------------------- I hereby certify that I havepr9j9red this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules r/ /pe-oulations of Sa Joaquin cal Health District. 4 (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). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ,Tt 'Q- -- -------------- ----------------------------------------- DATE--------- --------------------- REVIEWEDBY----------------------------------------------------- ------------ --------------- ------ DATE------ ----------------------------------------------------- BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------ ----------------------------------------- Alterations and/or recommendations----------------------------------------------- --------------------------------------------------------------------------------------- ----------------------- ---------------------------------------------------------------------- -------------------------------------------------------------------- --------------------------------------------------------------------------------- ------------------- ---------------------------- ---------------- ------- ------------------------------------------------------- ------------------------------------------------------------------------------------- FINAL INSPE TION BY: Date------- ------ Z = ------------------------------- 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.