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�r FOR OFFICE USE: a lP Permit No. •-- 7c ---------- - -------------------------- ------- APPLICATION FOR SANITATION PERMIT -------------------------- - (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 Ordina ce No. 549. JOB ADDRESS A CATION k ---------•-- - - `- - - --'----� R Phone--------------------- Owner's Name---- ---' --------- ------------------ ----- - ------------------ Ph Address---------------- ------ --`-------------------i " '----------------------------••----- Contractor's Name------- -- ® �.�....a----------------------------------------------- Phone. O � s Installation will serve: Residence �partment House ❑ Commercial E] Trailer Court C] Motel [3Other ❑ g f- Number of bedroomsS--' Number of baths A_ Lot size 1% --------------------------•-------- Number of living units --- Water Supply: Public system ❑ Community system�❑ Private [�epth to Water Tale Character.of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam-[D Clay ❑ Adobe hardpan ❑ Previous Application Made: (If yes,date--_-------------- -) yNo P--",New Construction: Yes ❑ No [ '"FNA/VA: Yes R;- -rNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: . ( P No se tic tank or cesspool permitted if public sewer is available within 200 feet.) �r t M4 Septic Tan{ry- Distance from nearesf'well-.-.._---.----_-Distance from foundation-------------_----.MateriaL� -.----------------------_------------------- No. of compartments--$ -------------- ---- size ---------------------Liquid depth ----`- Capacity Disposal Fi � Distance from nearest well-------------_a`Distance from foundation-------..------_. .Distance to,nearest lot line---------_------- [6'1�� Number of lines-----------------------------------Length of each line-----------------F-------- -Width of trench------------------------------------ v!�' Type of filter material----•--------------------Depth of filter material----------'*'-'.--=-Total length-----------------_ -•-•---------•-------- µ // �{ \ Seepage Pit: Distance to nearest well---�.�-------Distance fr m foundation-_45?--------- e to nearest l lie-- ---- \ r%},� Number of pits_-.`--f------------Lining material-,� ---Size: DiameterjP jejN /PDepth-----��-''------------------------- p t„I* Cesspool:l Distance from nearest well---.-------_----Distance from foundation--------------------Lining material...-{...-........................... ❑ Size: Diameter------------- ---------------- -------Depth---------------------------------------------------i-Liquid .Capacity----------------------- gals. } -�° Privy: " Distance from nearest well------------------------------------------------Distance from nearest building-____...-----_---------_----------------- Distance to nearest lot line--------.- ------ -- Remodelin and/or re airinx'(describe): ------ - r 9 p g • -Ire- -------------------------------- -- i X ---------------=------ --------------------- --------------------------------- ------------------ -- I -------------------------=-- ------------------------------------- ---------------------•-------- s = ------------ --------------------------------------------- -------------------------------------------- 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 laws, and rules and regulations of the Sa Joaquin Local Health District. A Contractor] (Signed)-- - -------------------- -- -- ----------- ------ -.•----------------------------------------K -------- - -----------{Title) '�'�`., k (Plot plan, showing size of lot, location of system in relat' to wells, uildings, etc., can be placed on reverse side. 4 FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY- ------ ------------------------------------------------ DATE__6----------- --------------------- ----------------- REVIEWEDBY------------------------------------------------------ ------------------ ----- ----------- ----------------- DATE - BUILDING PERMIT ISSUED-------- ---- ---------------- --------- DAT E------------- ------------------------------ - -------------- Alterations and/or recommendations---------------------- ------- --------------------------- ----- --------------------------------•-------------------------- ------------------------------------------------------------------- -------------------------------------------- 4 '_I ------- -..-...... -------------------- 10 Date-- FINAL INSPECTION BY:.. -------- ---------- _ ---- --------- - --------• --------------------------------------- ----- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. `i300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.a.co.