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FOR OFFICE USE: I -------- ---- ---- -------- Permit No. .. -------------•-•--.. --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Com lete in Duplicate) `r ------------------------------------ - -------- ------- { P�P � Da#e 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 here described. This application is made in compliant with County Ordinance No. 549. '71fr6_3 F-1 ._. Oil JOB ADDRESS ND LO ION ___ ------ Owner's Nam -- --- --- --- -------- - --•• --- ---------------------------------•---------------------------------- --i--------- ---------------- Phone------------------------ .. - - - - �` Address--------- - ---------- Ph C r one Contractor's Name----- - ---- --- �:.__ - - artment House Commercial ❑ Trailerl.Court ❑ Motel ❑ Other �5,t2Z� , Installation will serve: Residence ❑ Ap ❑ Number of living units: _^___ Number of bedrooms =__ Number of baths _I---- Lo} size I Water Supply: Public system ❑ Community system ❑ Private [Depth to Water Table ____.__ ft. Gravel Sand Loam ❑ Clay Loam ❑ Clay �obe❑ Hardpan ❑ Character of soil to a depth of 3 feet: Sand ❑ ❑ y Previous Application Made: (If yes,date__-------_-------- _) No ❑ New Construction: Yes E] No E] FHA/VA: Yes ❑ No El TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feed.]e Septic ank: Distance from nearest well___U_____Distance from foundation___ ______._-.Material.. '? --'-------- (----------- Septic - --- - X-�--�-- - q �4 `p. / I Distance from nearest well."Sp_�_._--Distance from foundation----------------Distance to nearest lot line'_____ _______� Disposal Field: F r L� Number of lines-----------I______._.;;��---------Length of each line__.._�1J---,--i�--------Width of trench_�__f--"-------------------- Type of filter material_______ �C Depth of filter material----.(_---- -_'----Total length-------X-0---------------------`----- r ,------ 1 /D-•__.___.Distance to nearest lot iine__...5________ Seepage Pit: Distance to nearest well------�_{7_P.......Distance from foundation__-____ - �- Depth.___�'S----------------- i4 tNumber of pits- . l----------Lining material_____S--.TZ-_-----size: Diaineter._._- K Cesspool: Distance from nearest well-----------------Distance from foundation-----I,----------- Lining material------ ----------------------"-ads. Depth ----------._Liquid Capacity----------------------------g ❑ Size: Diameter----�----.....-------------- ,I �' -----------------Distance from nearest building. Privy: Distance from nearest wail------------------- - ❑ Distance to nearest lot line--------------- ---`. --- ------------- Remodeiing and/or repairing (describe)-------------------------------- -------- ----- -------- ----------- -----------•,------ ---------------- -----=------------ ---------------------- --------- ------ --------•-------------------------------••--------------------------------- I hereby certify th t 1 hav prepared this a 'on and that the work will be done in accordance with San Joaquin Count Q ordinances, State laws nd r VIS and regulat' ns of a San Joaquin Local Health District. M` _ - - - ------- -------- --------------------------------------- (Signed) - ` � and/or Contractor) ` j ----- -- (Title)- : - - ------ i [Plo# plan, showing size of lot, lata#tan of syste i relation o wells, buildings, a}c., ij an be placed on reverse side). ' FOR DEPARTMENT USE ONLY j 'I `S— ---------- ------- --- APPLICATION ACCEPTED BY--------- -- ------------------------- --- DATE-_-- ----------- - - - ---------------------------------------------------------- DATE_ -- ---------------------------------------------------- - REVIEWEDBY------------------------------------------ - - -------------------- DATE------------------------------------------ ------------------ BUILDINGPERMIT ISSUED------- -------------------------- -------------------------------------------------------------! and/or recommendations:------.---------------- ----------------•-----° ----------------------------------- ---------_------- _-____4_ ----- --------- ---------•--•----------------------------•---------- ------------------------------------------_------l-------------------------.---------------------------------------------------._ - Y }i t _________-----------_------------------- .--- --- ---- ---- Date---- - -- - -•--- - --------- ----------- ------ FINAL INSPECTION BY______ __ __________ - ��''x 1 SAN JOAQUIN LOCAL HEALTH DISTRACT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 west 9th Street Stockton,Californiaodi,California Manteca,California Tracy,California i I� F.P.0 O.