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FOR OFFICE USE: - --.la/3-X67---- ------ -------f - -------------- ------------- - ---------- 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, t JOB ADDRESS AND LOCATION-- � - ---------�.-- 41 ` ----- ---- "�------------- --------------------------------------------- Owner's Name-- ......---� ---•----------�---�------ --------------- - Phone_q� _`-711& - -Address------------- '-- ---- --- �----------- Contractor's Name------ - ---------------------------- -------------- Phone-------------------- ------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court E] Motel ElOther [I Number of living units: �.____ Number of bedrooms- Number of baths I___ Lot size -__ _f- -- ----------------------------- Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table ------ - ft Character of soil to a depth of 3 feet Sand ❑ Gravel ❑ Sandy Loam [I Clay Loam [I Clay E] Adobe Hardpan ❑ W' P , Previous Application Made: (if yes,dd te---------- -- ---- 1 No ❑ New Construction: Yes ❑ No F] FMA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: r (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se tic,Tank: Distance from nearest well-__----____Distance from fo ndation--Ao--.----..- Ma�ial�. -----------------------------------f 4' ' x /`� -. --- Ca acit Na. of compartments-----------�.--------5ize_ -x- ----- - ---------Liquid de�h-..-7- 1 P Y ^ Disposal Field: Distance from nearest well..----.....Distance from foundation...... _ __..Width of #Tench--.Distance to nearest I S!------ -�t)ine_-S .--_- /�1__._ Number of lines.--------I- ------------------Length of each line--_-----rf__-.-- r ----.e-------------- x Type of filter material . AC Depth of filter material____--�-'?.__ g Total length ----�2?--------------------.- o- Seepage Pit: Distance to nearest well.......---------Distance �f.q m foundation----l 0- ----_- Distanc pito nearest lot line------------ i -------- Number of pets.-- !..-_�.__.._.--_Lining materiaL___`_'�4__�-�__r Size: Diameter__'. - --Depth_____2:.�-_---------------- - Ces' spool: Distance from nearest well ----------------Distance from foundation.- --------- ..Lining material--------------------.----------------. ❑ Size: Diameter. -- �--------- ---- --- -----------Depth---- ------------- ----- -------------------- - --Liquid Capacity-- ------------------- -----gals. I -----.-Distance from nearest building Privy: Distance from nearest well � 9------- ---------------------- � ❑ Distance to nearest lot line--------------------------------------------------- -------------------------- ------:-------- ------------r---- ------------ ------------ - Remodeling and/or repairing (describe):---- ----- - ------, = -------- - -----------•-•14 - �f.i -------- ----- ------------------------- - ------ -----:------------ -------------------------------------------------------------------------------------------------------------------------------- - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State lays. and rules and; regulations of the San Joaquin Local Health District. -- --------_------------- -------------(Oand/or anor Contractor 1L' .` ------ - / I (Signed)--- $Y ------------•------- ---------------- --------------- ---- ---------=--------------- -------------(Title)-_------ ---------- ---...------------ .....------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). I R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _. _ - -- - - ------------ -----------------------I------------------------- DATE-- ---- r `�' - -- ------------------- REVIEWEDBY----------------- -------- ------- ;€----- -------------------------- ---------------- ---------------------------------- DATE------ ------------•---------------------------------------- BUILDING PERMIT ISSUED-------- -- -. 1 - ------------------ ----------------------------------------------- ---------------- DATE Alterationsand/or recommendations."...------------- ----------------- ...... - ---------------------------- -------------•------------• ---------------------------------•---•---------- -..----•------------ ----------- - --------------------.---- ----------------------- -------------------------------------------- -------- ------- ------------------------------ --------------------------- ------------------------ ----- - -------------------------------------------------- ------ ............... . -... .. ----------- - --- ------ -- -- FINAL FINAL INSPECTION BY:. V , fa� � '� Data � - I I - - + --------------_---------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ha:ellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street i Stockton,California Lodi. California Manteca,California Tracy,California E.H.92M 1-67 Vanguard Press �— r