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FOIL OFFICE USE V_�7 I _...__..__.:-- �� _---_�t__ APPLICATION FOR SANITATION PERMIT Permit No. __�. f,�...`�....__ --------------------------------------------------------- (Complete in Duplicate) rc -- This Permit Expires 1 Year From Date Issued Date Issued ..........?. . .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 LOCAT ON___'I ar,------ ; Owner's Name ---------- --._------•--------------••-- Phone__---•-- .......... Address --- •-• - -••---•--... -- - ------------------ -- --- -- - Contractors Name................ - ----------------------------------------•-- ............ ............................ Phone................................... Installation will serve: Residence &'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [I Other ❑ Number of living units: --- Number of bedrooms •F- Number of baths ---/.. Lot size -_1_azet g_'................................ Water Supply: Public system ❑ Commur6ty system E] Private �fto Depth to Water Table -� . Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: {If yes,date____________________) No 21' New Construction: Yes @�rNo ❑ FHA/VA: Y 'No,1R`_' TYPE-OF INSTALLATION AND SPECIFICATIONS: - (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r Septic Tank: - Distance from nearest welt_`�0__--_Distance from foundation---«_--------.Mater1al...__�:_�r�/_'r..................... No. of compartments __._ ".—/ 109.;.'L'iquid depth___._ Capacity.-j?�D CY� P •- ------------Size__ ------------ •-------------- Disposal Field: Distance from nearest well--- ---------Distance from foundati n____I ___.__�.Distance to nearest lot line-.O ...... Number of lines----------- _ . ength of each line___g$ Width of trench._1Z________------------------- Type of filter material./ fA.___.-- epth of filter material____ d"_'_�________Total length_...�f� .�_______________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation.....................Distance to nearest lot line---------.--__-_. ❑ Number of pits-----__--------------Lining material..-.--------------------Size: Diameter____-j---------------,Depth................................. �{ Cesspool: Distance from nearest well-----------------Di tante from foundation--------------.____.Lining material..................................... ❑ Size: Diameter----------------------------------_Depth_---•- =--------•--•------------' Liquid Capacity.. q --------------------------gals. Privy: Distance from nearest well-----------------------_-------------------------Distance from nearest building________-_-___________________-______-___. ❑ Distance to nearest lot line--------- --------------------------------------------------•--------------------- Remodeling and/or repairing (describe):------------ - ----- --------•------------ ---------------------•--� - - - ---- --c-/ -- - .....-- -- -- - --- --- - - -• • ------ --- r •- I hereby certify that I have prepared this.appli tion nd that the work will be done in accordance with San Joaquin County ordinances, State laws, and- rules-arid regulations of the San Joaquin-Local Health-District-. (Signed)------------ - - rU ------- - --------------------- (0mwAw-a*4or Contractor) By:------------------------------------------- ---------------•-•---------• - , -- ------------(riiifle)-••---- /L-- .._-....:..-------------- (Plot plan, showing size of lot, location of system relation to wells,buildings, etc., can be placed on reverse side). 4 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- _ ___ DATE_. • ..____ -� REVIEWEDBY---------------------------------------- -`- -----------------�`-."`--------------- --------------------------- DATE------ ------------- BUILDING PERMIT ISSUED-------------!•-•----------------------------------------------------------------------------------- DATE-------- Alterations and/or recommendations:------------------------------------------------------------------------ •--•--•-•--•- -------------------------------------------------------------!-----------.-. ---------------- ----•----------------------•-•------•-------------------------•--------------•••-----•••--•--------•------•-•----•---------•---- ` -----•--------------------------------•---------------._.------------ ----•----------------------------------------------•-•--------•-------------__________------------------.---.---------_:_-------•_--------- r FINAL INSPECTION BY:...._C..... —5---------------------- --- Date----- `--------- ------------�-- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South America,Street 30W" e.t Oak.Striet .w ay `,� X1.24 sycamore Street 205 Wes!91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED a-59 2M 5-5I7ATr_A9