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FOR OFFICE USE: + �/ s ____________ --------------- --- -------------------- APPLICATION FOR SANITATION PERMIT Permit No. -------------- -- ---- --------------------- (Complete in Duplicate) This permit Expires ] 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 described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AN OCATION---------------- ------------�� .R. .>� ---------------------------------------- Owner's Name f ' ... -------------- V�i—------- ---------------_----- - ----- Phone------------------------------------ Contractor's Name C SIS-87 ---------------------------------`-------------- -------- ----------. Phone----•-----••------------•---------- Installation will serve: Residence W�artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___- -_ Number of bedrooms ._-2--Humber of baths _.-_-_ Lot size Water Supply: Public system ommunity system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sand am E] Clay Loam E] Clay E] Adobe ardpan F]Previous Application Made: (If yes date_________ ----------) No New Construction: Yes ❑ No 'A_/V/1: Yes ❑ No �--' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic nk: Distance from nearest well_______-------Distance from fou-ndation----AQ_.--___Mate�al. ________ �___-------. No, of compartments._1_-_--- -----------Size___ j(-r?---_---Liquid dept h-----f�..__-_ ___------Capacit y.__ -.---___ Dispos ield: Distance from nearest well,-.-4 _.Distance_from.,.fou,ndation__ G-).__r-..,_.D,istance to nearest lot line-5--/---- Number of lines____. _______ __________________Length of each line--- _.SV---4:_5'_-_Width of trench a-y,__k____._______.___. Type of filter material___._jVZ_- -epth of filter ma�erial____l4--�r_____Total length___-, - -----21------/ r ,1 Seepa1 it: Distance to nearest well______________________Distance from foundation___._____-__._____..Distance to nearest lot line___-___-______.__ �' q Number of pits----------------------Lining material----------.---4---------Size: Diameter----------------------- Depth---- J t Cesspool: Distance from nearest well-----------------Distance from foundation---------___-------Lining material -_____------------------------------- pQ ❑ Size: Diameter Depth -------:-------------------------Liquid Capacity-----------------------------gals. Privy: Distance from nearest well_________________________________ --------------Distance from nearest building El Distance to nearest lot line-- --- -------------------------------------- ------------------------- -------- 0 Remodeling and/or repairing (describe): _..-_.___. _ �� «� S -- ► -------------------------------------- --------------•----------------------------------------------•--------------- ---------------------`--------------•- ------ -- ------ ------ ` -- }D I -------------------------------------------------------------------------------------------------------- ----------------------- -------------------------------•--------------------------------------------------- --------------------------------------- I hereby certify that I have prepared this application'and that the work will-be donelin accordance with San Joaquin Coun_:_ ordinances, State la and ruleegulations of the, San Joaquin Local Health District. [Signed __6 -- -^ --.- -----_----------I --------------------------------------------'-•------------------(Owner and/or Contractor& % By:----------------------- ----- ------ 2z ---= ---------------- --------- (Plot plan, showing size o t, location of system in relat%Wfo wells, buildings, etc., can be placed on reverse side}. 1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- - --- ---------------- --------------- DATE--------f' l y/ REVIEWEDBY----------------------------------------------------------------------- f - �--- -------------- - ----------------------`- - ---- ---- --------------------------------- DATE-------- -----------•---- ---- --------------------------- s BUILDINGPERMIT ISSUED---------------------------------------- - ------- ----------------------------- DATE------------------------------ --------------------------- -- Alterations and/or recommendations:------ ---- ------- i------------;-------------------------------------� ---------------- ----------------------------------------------------------------------------------------------------------- ----------- -------------- k -----•-----------------------------•--------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------- --------------------------------------------------- FINAL INSPECTION BY: /T f= --------- _ Date_....1� � 1 `Tr * SAN JOAQUIN LOCAL HEALTH DISTRICT % 1601 E.Haielton Ave: ` t ., 300 West Oak street *, 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California .Ma teca,California Tracy,California F.P.CO.