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FOROFFICE LISE- APPLICATION FOR SANITATION PERMIT Permit No. 1o� / --------------------------------------- ------- - ------ - --- ---- -- -- ---- --- -------- --- -- (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 Ordinance No. S49, JOB ADDRESS AND L CATION_ . ` ` ------ � t' - Owner's Name qat- - - - ------ Phone------------------------------------ Address -------------------- • --- Address.......... �� -------------------• - f Contractor's Name------ `jam `T ----------------------------------------------------------------------------------------------------- Phone.." . C 7g Installation will serve: Residence ❑ Apartment House ❑ Commercial 0 Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ----/__ Number of bedrooms ___ Number of baths _1-_-_ Lot sizeza-e—i—C— Water Supply: Public system E] Community system Private [:] Depth to Water Table ;?._ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [Hardpan ❑ Previous Application Made: (If yes,date---------- .........) 'N;` New Construction: Yes ❑ No FHA/VA: Yes ❑ No ^ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 204 feet.) ` Septi ank-`! Distance from nearest well _.__.__.____I_Distance from foundation_i----------i------Material-----------------------------------______________ fNo. of compartments------------------------I-Size-------------------------:------Liquid depth--------------------------Capacity----------------------- Disposal i Distance from nearest well-_______________.Distance from foundation._JQ__/.I____Distance to nearest lot line_0'�__�_.._ Number of lines------t---------------------------Length of-each�line-_- .3_a-_f__--__-.._.Width of trench._._eg-4_,._�`__.._________-_- / `, r , Type of filter materiaL____�_ _r1�__�____Depth of filter mater�a!___ _�___��._.._.otal length________�_[�___ ----------------- __ Seepage Pit: Distance to nearest well.-------- -------Distance from foundation_ll-}__"_ ____.Distance to nearest lot line- _ ------ r I- Number of pits...--------------Lining material___ (._..Size; Diameter-_._3-3---`..___Depth_._._.�J-----�.________- � Cesspool: Distance from nearest well-----------------Distance from foundation Lining material----.-------------------------------- Size: ___._.__- -----------Size: Diameter. Depth ` -----Liquid Capacity---------------------- gals.00 Privy: Distance from nearest well--------------------------------------------------Distance' from nearest building------------------------------------------ ` ❑ Distance to nearest lot line---------------------I----------------------- ------------------------- ---------------------------------------------•------------------ -- - Remodeling and/or repairing (describa): •- ------------------------------•------------------ -----------•---------------------------------------•---------------- --------------------------------------------------------------•-----------------------------------------------•----------------------------------------- -------------- ----------------------------------------------------- / 1 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 gul tions of he San Joaquin Local Health District. ( (Signed) - ` - ------------ ------------------------------------------------- ----- ------------------------------------(Owner and/or Contractor) i By:-----------------------------------------------------------------------------------------------------------------------------------(Title)--------- ---------- --------- ------ - - - ------- (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 -- ---n-------------------- DATE-----�---- - ----�'�-��-------------- REVIEWEDBY-------------------------------- ------------------------------------------------ DATE-------- - BUILDING PERMIT ISSUED------------------------------ ------------- - DATE--------------------------------------------------- Alterations and/or recommendations:-----b�1�/ s �J � G� =------------------•---------------•-----------------•------------------------------- ---------•-------- ---------- ----------------------------------------------------------- ---------- -------------------------------------------------------------- -•------------------------------------------------------- -------•---------------------------------------------------------------------------------------------------------------------•------------------------------------------------------------------------------------------------ F FINAL INSPECTION BY:....- ------ Date.--- -- �A'?0 ---- --- -- ----------------------------- , SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.C o.