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FOR OFFICE USE:4r- ------------------------ ------------------------- A_ ---------------- APPLICATIQN FOR SANITATION PERMIT Permit No. . . ......:..:. ----------------------------------------------- ---- --- (Complete in Duplicate) - G This Permit Expires 1 Year From Date Issued Date Issued .__ t---____._� t 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 compliarice with County Ordinance No. 549. JOB ADDRESS AND LOCATION.4-_�J. --------- ------ Owner's Name-------- 1 �_/ � _: p --------------------------------•------------------------------------------------ Phone................................ Address............�� 3-/,4-~---_s:�?�f Contractor's Name------------------------e ra__—.,�, --e,/-- ------........... Phone................................... Installation will serve: Residence E'Apartmant House ❑ Commercial.[] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ../-.- Number of bedrooms ,&_ Number of baths _/---- Lot size _-44- __ ',��.`........................ Water Supply: Publics stem t pp y: y I�Commuriity system ❑ I}rivate ❑ depth to Water Table -��ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2--'-Hardpan ❑ Previous Application Made: (If yes,date--------------------) No .12" New Construction: Yes ❑ No v❑�FHA/VA: Yes ❑ No R' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is availableT within 200 feet.), f Septic k: t well ..---Y _ foundation,/ e. -------- Distance rom _ --------Material----------------- No. -t--_ Noof compartmefs- _ - Size_: __ _._._. �_�.�.-----Liquid depth_-•X_ --------------Capacity...r•�-f�--Q-----•- Disposal Field: Distance from nearest well...-` - __-_Distance from foundafion- /A./.-..Distance to nearest lot Number of lines________.__ Length of each like_____ --------------Width of trench__s9 �------------------------- r ® fir.--:,------- .�� • Type of filter material __ � Depth of filter material----,��-----:__Total length---------�*:__ --__-_-__---___---- E, .. p ' Seepage Pit: Distance to nearest ell.___._._—�___--._-Distance from foundation__.._�,�.___.D�st �� to nearest lot line_______......._ X, [� Number of pits----------------------Lining material__—XJP4�._ ..Size: Diameter'--%-.0;'- .----Dept h__�`s`�_'___.----__.--------- Cesspool: Distance from nearest well-----------------Dist nce from foundation-....---------------Lining material------__-_-_---_-.--_-------_--_-_. ❑ Size: Diameter----------------------------------------Depth---------------------•---•-.-----------------------Liquid Capacity------------------------_--gals. Privy: Distance from nearest well______________________________--------------------Distance from nearest building------------------------------------------ Distance ___----_-------___---_----_-_-----._.__.Distance to nearest lot line---------------------------f----------------------------------------- Remodelin and/or repairing describe ------------------ --__ �_�r_____ ----------------------------------------- -- - -- - - - - - - - > �r `/ �' - --------------------------------------------------------------------------------=----•-----------:------------------------------------------------._ ------------------------------ ----------------------------------------- ----------------------------------------------- ------------------- ----------------------------••----- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. --�` � - 1, (Signed) --------------- ------ - ------ -------------------------(Ow��or.Contractor). By:--------------------------------------------••------------- = ----------------- (Title) '--------------------------------- (Plot plan, showing size of lot, location of sys a in relation to wells, buildings, efc., can be placed on reverse side). I FOR DEPARTMENTTE ONLY APPLICATION ACCEPTED BY_. .� `� ----------------•--------------- DATE---------- -4. -- - -------------------------- REVIEWEDBY------------------------------------- -----------------------------------------------••----------------------=---•------------ DATE.. = ... BUILDING PERMIT ISSUED-----------------------------------------•------------ ----------------------------------------- DATE_--- ------------•-------- -Alterations and/or recommendations:-------.------------------- ---- "' ------- --- ------- •-----•----------------•-•----•------------------------•---------- --------------------------------------------------------- .t� = -------------- FINAL 'INSPECTION BY:.4----- -:--. %1 ----- -------- Date_..._ -` f U----- ' SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street + 124 Syiamore Strriet- 205 West 9th Street f � Stockton,California [ Lodi,California Manteea,California Tracy,California E0.9 REVISED 0-55 F.P.00.2M 6.60 - P� 1� •