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FOR OFFICE USE: ' - ----------------------------------------------------- ------- ---------------------------- -- -- ------------- APPLICATION FOR SANITATION PERMIT PermX-- No. ----------------------------------- --------- --------- (Complete-in Duplicate) - � _ i D:This Permit Expires 1 Year From ate Issued ' 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. r JOB ADDRESS AND LOCATION % -- '`� Owner's Name--- -- --- - --------- -- - - -------------------------- -- - ------ Phone......--------------�_----------- Address------ - -------------------------------------------------- -------- ....__ _�__ .____..J ________________ � i O yrs I i Contractor's Name---------4 �-s-tr------- Phone Installation will serve: Residence [� Apartment House ❑ Commercial ❑ Trailer Court E] Motel [j Other ❑ r L�As i�� 1 Number of living units: __ �._ Number of bedrooms _sl_ Number f baths-_7� Lot size ____.-_-.��--_�_____ _______________________ Water Supply: -61Public system'❑ Community system [] Private [ Qepth7to Water-Tae _.�..- --ft I Character of soil to a depth of 3 feet• Sand E] Gravel E] Sandy Loam ElClay Loam 16Clay,❑ Adobe ❑ Hardpan C] Previous Application Made: (If yes,date-----.............. ) No E] New Construction: Yes [INo ❑ FHA/VA: Yes ❑ No El TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic`.tank or cesspool permitted if public sewer is available within 200 feet.) �, I h Septic Tank: Distance from nearest well----- -----------Distance from foundation_ --------_.—Material _________________________________.___....___.-- ❑ No. of compartments-------- ----- ----- -----------Liquid depth------ � . y...--- --------------- Disposal __-..Ca aut Disposal Field: Distance from nearest well.................Distance from foundation--------------.___..Distance to- nearest lot line___________.____. ❑ Number of lines---------------------------------Length of each line__ --------------------------Width of trench:.-.-----------------.----.____... Type of filter material-------------------------Depth of filter material----------------------- length-.-..--_-----------------------_--_--�--+ Ses � { Distance to nearest well___._.......... from foundation____JQ_f______-Distance to nearest lot line__.S_*-_-_____ ❑ Number of pits___ -----/_-----------Lining material._.._S± p ---- Size: [ e#e�--�-�fi---'z-�.:`Depth-- 4'S-�------------------- Cesspool: Distance from nearest well ________________Distance from foundation................. ..Lining material_..74.----------._'-.----._____ ❑ SizeDiameter- -- ---------- - ..........Dept h----- --- ----------------------------.Liquid Capacity-------------- ------------gals. \� Privy: ( Distance from nearest well.----_---------------------------___-------..Distance from nearest building_y -------------- -- ------------ ❑ Distance to nearest lot line ------------------ - ---------------------------------------....---------------------------------------------- '-------------------- Remodeling and/Ir.r'epairing��descr;be)------------------ --- 464 ---- _ P _ ' v, I __ _ ---------- --------------- ---------------------- ___.�v----- _________.._ ----------- ____...__..___-_____---- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State3laws, °r les and regulations of the San Joaquin Local Health District. (Signed)- -- A=._- ------------------------ -..(4v�nea.and/or Contractor) - ------------=----- - -- F. 1 , BY: _ ------------------------------(Title)-- --- --- ------ - ------ --------- (Plot plan, showing size-of lot` location of system in relation fo ells, buildings, etc., can be placed on reverse-side).- . - t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY �r ---------------------------- REVIEWEDBY-----`----------------- I------------------- -----• DATE---------------- ------------------------------------------ BUILDINGPERMIT ISSUED---. ----- ------- ------------------- ------ ----------•--------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations---------------------------------------------- --- ------------------------------------------------ --------------- ------ --------------------------------- - --------------- --------- ---------------------- ------------- --- ---- ....... ---------------j------------ --------------------------------------------------------------------------------------- r FINAL INSPECTION BY: - -----------_----- ---------------------------------------------------------- ----- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi. California Manteca,California Tracy,California E.H.9 2M 1-67 Vanguard Press