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FOR OFFICE USE: ____________ APPLICATION FOR SANITATION PERMIT Permit No. -- --------------------------------- --------- (Complete-in Duplicate) . ---------------- This Permit Expires 1 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 AND,60C TI N, 0a . . ........ r. a Owner's Name ---- ------ ----------- --------------------- Phonv_06_ r Address----------------------------------------------- ---- ------------------ -•-�- Contractor's Name 11{-—------------------------------- Phon10"7 �T Installation will serve: Residence x Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/----- Number of bedrooms __.Z Number of baths-1_.._ Lot size __ ------------------______ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table .- - ft Character of soil to a depth of 3 feet- Sand ] Gravel ❑ Sandy Loam ❑ Clay Loam A.- Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date................. ) No)� New Construction: Yes ❑ NoX FNA/VA: Yes ❑ NoX TYPE OF INSTALLATION AND SPECIFICATIONS: {No septic tank or cesspool permitted if public sewer is available within'200 feet.) Septic Tank: Distance from nearest I.9 _ __..._Distanceromfoundation_. ,Materia l ___.__ ________________ - � ___ -------- _____ No. of compartments. Size_ _ �_ 5---_ Liquid de th_ Zf _ A _ _ • Disposal Field:. Distance from neapast well_-- Q.---------Distance from foundation__9_3--------Distance to nearest lot line_IQ---_-___ i Number of fines__ �i _________ ____ Length of each line_..g0.�-._. Width of trench_.. -_-_ _.__ Type of filter material__. ...Depth of filter mate Total length_- Seepage Pit: Distance to nearest well-------------_--------Distance from foundation----------------------Distance to nearest lot line__.______-_._-__. ❑ Number of pits--- ------------ ----Lining material---------------------. Size: Diameter------------------.....Dept h--------------------------.-.---- Cesspool: Distance from nearest well ________________Distance from foundation,-----------..... ..Lining material------------------------- n Dept Liquid Capacity--- ------------------------gals. I ❑ 5ize: Diameter- ------------ ----------------De th----- �-�-�---�----- - -- - ----..._.-- - - -- Privy: Distance from nearest well---_---------------------------------------------Distance from nearest building---------------------------------..____._- ❑ Distance to nearest lot line ------------ Remodeand/or repairing (describe):____._._.__ -- ------------------- ---------- ' --. ---: --------------------- ___1-- ----------- ----- --- --------- - ------ ------ -- ----------- ----------64-1 -------- - - -- ---- ------ -----------•------------------------------------------------------------------------------------------------------------------------------ I hereby certify that I ha epared this app ication and that the work ill be done in accordance with San Joaquin County ordinances, State laws, and r les nd regulation f the San tloaquin Local ealth District. (Signed) ------------ --- ---- -- --- ------ ------%-- ------------ � -------- -----(Owner and/or Contractor) g ] By:-------------------------------1------ - -- -- ------ (Title)....--- (Plot plan, showing size of to ,, oca4' system in relation to wells, buildings, etc., can be place on reverse•side). FOR DEPARTMENT USE ONLY j APPLICATION ACCEPTED BY- L �---- ----- DATE-�--�Z �. ..._-• REVIEWEDBY-:--------------------------------------- - ---- ---------------------------------------------- - ----------------•-------- DATE------- BUILDING PERMIT ISSUED-------- -- -- ------------------------------------ ---------------------------- DATE-- ---------------------- - Alterations and/or recommendations:----------------- --------- -- ------ ----- -------------------------------- ------------I------- -------------------------------- - ---- Date �U FINAL INSPECTION BY:-...-_.--� - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 F.Hazelton 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