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r K Ur[-K_t USE: =- �-��-�-----------------�� 1 APPLICATION FOR SANITATION PERMIT ------------ ------------ - ------------------ ---- I � (Comple+e in Duplicate) -------------------- - -------------- -- _ This Permit Ex fres 1 Year From Date Issued Date Issued _�_'- _�7 1 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__ 79z41U , -_- _ _ -- Owner's Name----------- _ ------------------------------------------------------ Phone------------------------------------ -------------------------- ----------- --------------------------------------------- - Contractor's Name_______ _____ _ ----------------•------ -------------- ---------- ------------------------------------------------------------------------- Phone......... Installation will serve: Residence f�Apartment House p Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _.'I___ -.-__Number of bedrooms __�_ Number of baths -1---- Lot size �v �_I-�-� i --------------------- Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table '4'ft. Character of soil to a depth of f 3 feet: Sand E] Gravel E] Sandy Loam [-] Clay Loam ❑ Clay ❑ Adobe® Hardpan Previous Application Made: {If yes date________ ---------- No CeNew Construction: Yes ❑ No P-'FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septi an Distance from nearest well_____________ Distance from foundation-------------- Material_______-____._._ No. of compartments---- ---------------- _Size-------------------------------Liquid depth---------- ----------- ---Capacity------------------- - ❑ Number of lines- rest well______._____ .Distance from foundation--------_'--._._--_.Distance to nearest lot line--------- Disposal F641�/ iDistance from nearest Length of each line------------------------______Width of trench Type of filter material-------------------------Depth of filter material------------------------ length----------------------------------------- See a e Distance to nearest well Distancem foundation_/.a..__________-Distance to nearest lot line__..C,� _ Number of Pits.---- ---------Lining material_-r--x--s`'G-��--Size: Diameter___- --�±-----.Depth-------e2 -................ Cesspool: Distance from nearest well--------------___Distance from foundation_.-----------------Lining material--------------------------- ❑ Size: Diameter. ----------------- ----------Depth----------------- ---------------------------- ----Liquid Capacity---------------------------gals. Privy: Distance from rea e'st well-------------- -----------.-----_ . .______.__...Distance from nearest building_----------------------------- - ❑ Distance to nearest,lot line------ ----------------- -------------------------------- I Remodefing and/or repairing (descr'ibe)______________ ---• ---------------------------------------------------------•------------------------------------ l1 -- ---------------- --------------------------------------------------------------------------- ---------------------------------------------- ----------------------------------: ---------------------------------- ---- 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, nd rules and regulations f the n Joaquin Local Health District. (Signed)--------------- r -------------------------------- ---------------------------- -- ------ -(Owner and/or Contractor) Br--------------------- -------------------------- ;----------- -• -----------------------------...... ------------------------------ (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-------------------- -------------------------------------- a -- ---------- DATE----`-'-�--- ----- - ----��------ --------- �- REVIEWED BY-------------------------------- - DATE A _ ____ ____________________...___-_..___..._.__._-__.________--__.__________.._ UILDING PERMIT ISSUED---•------------------------------------- --- ,. -- -------------- - --------------- ---------------- DANE----- �- -----------`------------------------------------- X -------- ---------- ------- --- Alterat' and/or reco ndations:._____.._-_---._..._ --------- - ------- ---------- --------------------------- --------------------- - ---------------- --------------------------------------------- l -------- ------- - -------------------------------- -- -- --------------- - -------------------------- - --------------- FINAL INSPECTION BY: :: Date '------ - -- -------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Haselion Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California .,-Lodi,California Manteca,California Tracy, Celifornia F.P.CO. r