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Aw V FOR OFFICE USE: i�---- . ----- E APPLICATION FOR SANITATION PERMIT Permit No.......................... --------------- --------- ------------ ------ I (Complete in Duplicate) � _� ------------------------ f Date Issued Q - t,..---.. -------------------------------------------------- This Permit Expires 1 Year From Date Issue Application is hereby made to the San Joaquin Local Health District for a permit to construct and install th work herein described. This application is made in compliance with County Ordinance No. 549. r?"� 1- V 7 7 0 1I--�. -.- -- -•- -------------------- ---------------- JOB ADDRESS AND LOCATION....___,__. " �G. Phone `►?=:.�.�.:�� Owner's Name- -.-G `----------- ----- Address 9 --� /:w.. ----------- C_Phone ------•-----------•---------.-•---- Contractor's Name ---. Installation will serve: Residence,% Apartment House ElCommercial 0,1Tra16r Court ❑ Motel ❑ Other ❑ Number of living units: __/___ Number of bedrooms ._-_- Number of baths -------- Lot size_._h_$X...11.,._�/............... Water Supply: Public system ❑ Community system ❑ Private JS Depth to Water Table 4� ter_ ft. Character of soil to adepth of 3 feeti Sand ❑ Gravel El Sandy Loam ❑t Clay Loam [3 Clay ❑ Adobe' Hardpan ❑ 1_. Previous Application Made: (If yes, date--------------------) No F] New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No [:1 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___S0_____Distance from foundafion___..�Q______. Materlal;._� ••-•-=---•--- fJ ® No. of compartments------------�_.----- Size ----------------------•-----,__-Liquid depth -------------------------- Capacity--f_j=4Q_4 tX Disposal Field: i, Distance from nearest well.. [ -.Distance from foundation...____ -/0 ...... Distance to nearest lot line.._ . ....... i Number of lines--- ----._Length of each line -..-----.---7d -f --_Width of trench ------------=--f..-•----•--•: Type of filter ma+erial._.�. _4? --Depth of filter material ---------- ,/9 ..... -.Total length -------------- Z15 -2______-----f.... l f t _ Seepage Pit: ; Distance to nearest well ----- Distance fro f��''undation___...L�.-'.Distan a to nearest lot Gne___..______.___. Number of pits .......... ------ Lining material..___ <rZ____.Size: Diameter ...... 9,5 -------_.Depth-...___---� . /....-----••- -----•• ---------------- Cesspool: { Distance from nearest well ----------------- Distance from foundation.________.___ -.___.Lining material__._________.- gals. ❑ Size: Diameter----------------------- ------ Depth ------------------------------------------- Liquid Capacity...----•----•--......._._. _g w, I __._Distance from nearest building Privy: � Distance from nearest well________________________________._- may, Distance to nearest lot line------------••------------- --------- Remodeling and/or repairing (describe): .. ----------------------------- -------------------- --. ._. -__------•----- =-------••------------------- •---------------••------••-----------------••----------------------------- 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 rues and regulatii5n f the San Joaquin Local Health District. f --- /�� ;; (Owner and/or Contractor (Signed) ---- ------------------------------ ---------------------'------•------------------------------------------------------------------- (T'itlej (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). .. r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ -I- -- DATE --F- -c -----------•----------- -- --- ------------------ --- DATE ---------------------------------------------------- ----•-- BUILDINGPERMIT ISSUED ---------------------------------- ----------- DATE ------------------------------------------------------------- Alterations and/or recom n atio --- --------------------------------------•----------------•------•---- ----_---------- ----...... ..------ - ------------------------------------------ --...-----.--------------------------------------- ..... -...................... -- _ - ------------------------...------....-------................... .._.. ---- �..�::` l" FINAL INSP TION BY ------------- ------------------------------------ Date-------- ----------------•----------------------- -------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street` 1 300 West Oak Street 124 Sycamore Street 205 West 9th Street ory Stockton, Callf4� $ Lodi, California Manteca, California Tracy, California EB 9 tILVISED a-59 2M 5-61 ATd t 4 -.