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FOR OFFICE USE: :-� ----------------- /.; APPLICATION FOR SANITATION PERMIT Permit No. ........................ -------------- ------------------ ----------------------- --------------- ---- ------------------------------- - -------------------------=------------- (Complete in Duplicate) This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descried. This application is made in compliance with County Ordina ce NIo. 549. JOBADDRESS AN LOCATION------ _ ----- - --------------------------------------------------------------------------------------- Owner's Name._r.4_1'-L!_`r ".�"'".W... Phone Address----- ee -------------------------------------------------------------•--•-------------••-•---------------_ Contractor's Name------• .-------------------f ---- Phone----------------------------------- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___I--- Number of bedrooms ___QNumber of baths ___�_ Lot size __w?U__�__��----------------------------- Water Supply: Public system [e—Community sysste'm El Private F1 Depth to Water Table _4.0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe larl4ardpan ❑ Previous Application Made: (If yes,date.__--,_.- ) No New Construction: Yes [:] No dM'FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se i jTa�nk: Distance from nearest well------ ---------_Distance from foundation--------------------Material----------------------------________.._-___-____. No. of compartments-------------------- 'r---Size---------------------------:---Liquid depth--------------------------Capacity--•--------------- Disposal Distance from nearest well-_-'-------Distance from foundation-10-------------Distance to nearest lot IinW76--- Number of lines---------I----------______ -------Length of each line--k-5-0---------- --------Width of trench------------------- --_ ---- _ -J v Q Type of filter material - '!.`G_ :___----Depth of filter material_---Irl ---------.Total length___.__-- ___. r Seepage it: Distance to nearest well_.......' ---------Distance foundation---lQ---------Distanr%e to nearest Igt line_________________ Number of pits-- ---------/----------Lining material------ --0L!�:Size: Diameter_--3- ----------Depth--- _J--------------- +� Cesspool: Distance from nearest welt-----------------Distance from foundation--------------------Lining material___.._...._______---------___-_____-. Size: Diameter--------------------- ------- -. --------------------- --------Liquid Capacity----------------------------gals. ❑ ------.Depth---------------- ---- Privy: Distance from nearest well---------------------------------------------`---Distance from nearest building-----------------------------------------. -p ❑ Distance to nearest lot line.--------------------------------------------- Remodeling and/or repairing (describe):-------- -------------- ------------------------------------------------------------------------------------------ --------------------------------------- -------------------------------------- -------------------•------------------------ t ---------------------- ------------------------------------------------------------------------------------------------- --------------- ------------------------ ------------ ------ --- --------------------------------- 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 rule regulations the San Joaquin Local Health District. (Signed) - ------------------ -----------------------------------------(Owner and/or Contractor) By---------------------------- Title (Plot plan, showing size of lot, location of system in re ion to wells, buildings, etc., can be laced on reverse side). EPARTMENT USE ONLY y APPLICATION ACCEPTED BY------------ ------------------------------------------- -------------- DATE-.---1 ` Q r ------- --------------- --------- --- - - REVIEWEDBY-------------------------------- ------• ------------------------------------------------------ DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED------------- ------- -- ---------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations .nd/or recommendations:___ - //------- - -- -4 / , i , f E-mc� lzF - - --------------- /I ,,f -------4.--u d�',l a6Zf.-- i' � ��a �' --- -------V"Y-Q---- -------_c � � r- _.- -- ------------- FINAL INSPECTION BY:----- -- .. t ------------- - Date-----------/7:7=------- - - ------------------------------ SAN JC9'AQ UIN LOCAL HEALTH DISTRICT 1401 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.0 r].