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FOR OFFICE USE: Y / __"_______-------------------------- APPLICATION FOR SANITATION PERMIT Permit No. --------------------------------------------- ------. (Complete in Duplicate) - � ` Date Issued ____�_-__'3-_�� ------------------______________________________.___.___ This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Me1.a District for a permit to construct and install the work herein described. This application is made incompliance with County Or ' ace No. 549. JOB ADDRESS AND LOC TION.. 'f . -- ------ --- - --- ---- Owner's Name------- — ------- ----------------------------- o, 7.- ...-- 6 -. Address. `r �'" -- � ' - ------- ..�-_. PhoneContractor's Name-- le .. -- -- ----`-- --- ------ ---------� fQ. � Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other p Number of living units: . __.N ber of bedrooms _Number of bat slot 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 ❑ Clay ❑ Adobe 0---Hardpan ❑ Previous Application Made: {If yes,date-----------.--------) No ❑ New Construction: Yes ❑ No [?T�FHA/VA: Yes ❑ No ❑; TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank-?r cesspool permitted'if public sewer-is available within 200 feet.) Se Tan istance from nearest well________________Distance from.,,foundation____.___________'.Material__..____._.___.___._____.______ .:.--------- ! No.iof compartments--------------------------Size-------------ti�-"y.__-_:_=Liquid depth--------------------------Capacity"-------- --------- �t Di al ;stance from nearest-well-��Distance froPri4oundafion___1V-___-___Distance to nearest lot line____ g 1" g ori Number of lines--------------- � _Total"len th_______�-�-•----------------------- p --" ___________ _ Len th of each line_____ Width of french__._ ___ _- T , Tye.of filter. material__ _____`____ -_'.Depth of filter material--- _.=__ ____-_ � s, i �, Seepage Pit: Distance to nearest well_______________ _____Distance from foundation Diameter_ ©'stance tonearestlot line---__.____:."..t Nu ber of pits-------------- Lining material________$-.___._ ___-- p ' -rte Distance frorn„nearest well_______ __. Distance from foundation--------- __._--^i . Lining material------------------------ Cesspool: _ ❑ Size Diameter �-': Depth . --------- - Liquid°Capacity ---- gals. Privy:. , ._ Distance.from nearest,well-___ --------- ________________Di itance-4r'om-nearest building---------------------------i__ ❑ Distance to nearest lot line_,_-_-.-,_______;______ . 1 ! Remodeling and/or repairing (describe]:: - _.____=_ _.---------- + ------------ i •-••-----••-------------- ------- -- - --------------•-- 1 # :� .. -------------- - - ----- ------------- --------------------------- - ------ --------------------------------------------------------------------------------------------=- ------------=----------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application,and that the work will be done in accordance with San Joaquin County f ordinances, State la s, and rules and regulations of the San Joaquin Local Health District. 1 (Signed-> -C' I �r'Contractnrl - By:---------------------------------------------'----------------------------------------- --- (Title)----------------------------- ------- ----------- (Plot plan,,showing size of lot, location of system in relation wells, buildings fe., can be placed on reverse side). F t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTS _ -___-- _ -- . DATE---��__-- - - --------------------------- REVIEWEDBY----------- 4 - ------------------------------ DATE--- - - ------------------------------------------- j BUILDING PERMIT ISSUED------......i----•--•-•-•--------------------------- - t DATE = t Alterations and/or recommendations: ------------------------------------- ---------------------- --------------•-----------------------------•--------------------•-------------- t ---------------------------------------------------------------------------------------------------- --------- ----------------------------------------------------------------------------- ----------------------------- - - ------- ------- -------------------------------------- ------ --"-------- ------ ------ ------------- -- --------------------------------•--- ------------------------------------------ FINAL INSPECTI0_U - Date. -- ----��--------------------------------------- S-A QAQU.I OCAL.-HEALTH-:DIST T .� 1601 E.Hazelton Ave. 300 West Oak SIre T 124 Syca ore Street 205 West 9th Street Stockton,California Lodi,California .' Manteca,California Tracy,California ES 9 REVISED E-S9 31A 3-'r.3 F.P.CO.