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FOR OFFICE USE: --------------------------------------- --------- APPLICATION FOR SANITATION PERMIT Permit No. �`l_0011 ........- ------------- - ---- -------------- --------------------- (Complete in Duplicate) �_. ,:= licate) � Date Issued -------------------------------- --- This Permit Expires I 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. 549. (LFp 33 A JOB ADDRESS AND LOCATION .....4 --- -- ---- - -------- a Owners Na -- - ------ ----- -----------------------•- ----------- ?-. Phone ----- Address ----- - - ---------------------•--. --------- Contractor's Name-- d-�' �� 4'`�`-�. ----------------- ------ Phone----------------- - Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .---j_ Number of bedrooms... Num�4,e baths 2�Lot size -----------------------------------------------------------d---.�. Water Supply: Public system ❑ Community system ❑ Private pth t ater 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.--------.- ) No ❑ New Construction: Yes ❑ No ❑ FHA/VA.. Yes ❑ No Ei_ € TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Z Septic (,k: Distance from nearest wells ___.--Distance from foundaion-__�d ....--Material.-- a .__-__________� 11 No. of compartments.......2 -- ----------.Size- Liquid depth------0.................Capacity../..r;?-dPo. - -- r Disposal Field: Distance from nearest weEl.... _.._Distance from foundation-./P../ �...........Distance to nearest lot line 5.... .... Number of lines...._..------------------Length of each line..7[2------------------Width of trench_--i----!..------- Type of filter material--_..__G.'R!-----Depth of filter material-....-.1.. .- -_--_Total length_.__. ................... Seepage Pit: Distance to nearest well__...................Distance from foundation--------.---------- Distance to nearest lot line--------------. ❑ Number of pits----------------------Lining material---------. .Size: Diameter_--------------------Depth-.------------------------------- Cesspool: Distance from nearest well.................Distance from foundation------------------- Lining material .-.-.--------------.---.------...� ❑ Size: Diameter----------------- --------------------Depth-------------------------------------------------- -Liquid Capacity----------------------------gals. Privy: Distance from nearest well-----------------------------------........ -----Distance from nearest building---------_.._______-_-.-_. ❑ Distance to nearest lot line ------------------------------ ------------------- ------------------------------------- ------------------- � Remodelingand/or repairing (describe}- ------------ --------------------------------------••-•---------------------------------------•------------------------------------------------------ --- -- ----------------------------------------------------------------- ------------------------- I herebyCcert' hat I have prepared this application and that the work will be done in accordance with San Joaquin Countyordinances, Sand rules and regulations of the San Joaquin Local Health District.(Signed) - --------- -------------------------------- ------------- and/or Contract 0 BY� c - - - ------ ---------------(Title)------- ------------ --------- ---------------- --- (Plot,plan, showing size of lot, location of system in r fion to-wells, buildings, etc., can be-placed-on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- -------------------- DATE. /-- REVIEWEDBY----- ----- -------- ------------- --------------------------------- =-------- DATE-------- -----------•-------------- ----------- BUILDING PERMIT ISSUED------------------------------------------------ -------------------------------------------------- DA-TE------------------------------------------------------------- Alterationsand/or recommendations:---- ----------- ------------- -------------------------------------------------------- -------------------------------------------------------- I i FINAL INSPECTION BY:. �- _ Date..-----------------------------------------------------------' ' ------------- 4I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave, 300 West Oak Street 124 Sycamore Street 205 West 9Th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CM