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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. 1:��J.T..:: --------------------------------------------------------- ------ -------------------------------------------------- (Complete in Duplicate) Y/� -----------------------------------------_____.-____'_ _ This Permit Ex ires 1 Year FromDate IssuedDate Issued ---- 1_I 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 AND LOCATION. p--- -------------- ...--•-- ---------------------------------------------------------- ; Owner's Name--------------r / ��.. e�-' ------- --- _ 1`1c5 °/ ----------- Phone------------------------------------ Address --------------------------------------- -----------------------=----------------- -------------------------------------------------------------------------- - Contractor's Name----------------------- •---------- ------------------------------------------------------------A-- ----------- Phone----•-••---------------- ... Installation will serve: Residence ❑ Apartment House [] Commercial ❑ Trailer Court'`❑ Motel ❑ Other& 770-41 Number of living units: ._j___ Number of bedrooms ________ Number of .baths ________ Lot"size ...... �7_-______________________________________________ ' Water Supply: Public system ❑ Community system ❑ Private X Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam,S Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If;yes,date------- ____.) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: it (No septic tank or cesspool permitted if public sewer•is available within 200.feet.) Septic Tank: -t ==Distance from-nearest-well-------- Distance_from:foundation._:-=:_ =_Mater.ial_--------- -----------_____________________., ❑ No. of compartments-------------------------Size--------------------------------Liquid depth------ -------------Capacity------------------------ Disposal ---------------------Disposal Field: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line_________________ ❑ Number oflines:Y=------------------------------Length of each line....-------------_.---____--•.Width of french.----..............__.-------------- Type of filter material----•---------------- ---Depth of filter material--- 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 fi•orn nearest well----l!2 5_D_-__Distance from foundation------6C---------Lining material-_________________________________- Size: Diameter-----------------------------------•--Depth--------- ------------------------------------Liquid Capacity--------- -----•-_••-----..gals. �. Privy: Distance from nearest well-________.______________________--_ --_-__.__._Distance from nearest building------------------------------__-_.._____. ❑ t Distance to nearest lot line------------------------------------------------- ------------------------------------•--------------••-------------------- --------------------- Remodeling and/ r repai ing (dosctibe).- --- bt = ' =•-••. - ------------------------------------ ---------------------- - ------------- .. •-- •• ----•---••- ----.. - ------- --------••---- ---••--------------------------- - -----------------•-----•----------.----------- --- ------------------------------- _._________________________________--------------_---___=:___�... ____________-_-_----------------- __....___-___ __tilile ___._-..__.._____.____________-________-___._�-------_.__-__-_----___-_...__-_ i I hereby certify that I have prepared this application and that th done in accordance with San Joaquin County ordinances, State laws, and.rules andr ulati6ns of the San Joaquin Local Health District. (Signed) ------(k. -------- ----------------- Owner and/or Contractor t By:------------------------------------------------------------------------------------------------------------------------------------(Title)-- __----------------------------------- -- ----------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). APPLICATION ACCEPTED BY-------------------- ---------- ------- ---------- - -------------------- DATE---f z k REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE. F - -----------------------�_------ BUILDING -------------------- - BUILDING PERMIT ISSUED--------------------------------------------------------------------------------------------------------- DATE--------------- Alterations an%r recommendations: ---------------- ----• -- -----------•------------- ---•------- .--- ---------------- ---------------------- -•-----------.-._--.. .... ------•--:_-_------•-----------�-----------•------------------------•-------------.-•-- --------•----------------------------------------- --------------------------------------- - -------- ----------- ---------- ------------------------------------------•---------------------------------�-jj---------------------------------------------•-----•-•---------------- � � - ------- Date__..._.` -- FiNAL INSPECTION BY: i --- ------------- J6, � SAN JOAQUIN LOCAL HEALTH DISTRICT f r 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California 0Manteca,California Tracy,California ES-9 REVIeEb e•89 F.P.Ca.7M 6-60 i