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FOR OFFIr-, 1SE: --------------- 9 ---------------------------- APPLICATION FOR SANITATION PERMIT Permit No. -------- ../__ --- ------------ (Complete in Duplicate) _..-_._._ This Permit Ex fres 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. .1 This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION...- / Y�'r- �N. .-1 -I------------- ---------------------------------------- ri Owner s Name----------- '`'F ---- ----- Phone------------------------------------ z �Address------------•- 3----.. C ------------------------------------------------------ Contractor's Name '-Xj -------- ----------------------------------------- Phone---------._--•------------------- Installation will serve: Residence JB Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I___ Number of bedrooms _2___ Number of baths _ - Lot size ____________________________________________________________ Water Supply: Public system ❑ Community system ❑ Private 0 Depth to Water Table Y-6- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam a 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: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well________________Distance from foundation________________ Material--______--_-___--_-___-___________--__-____-____. ❑ No. of compartments----- ------ ------- --Size------ ----------------- ---Liquid depth---------------- ---------Capacity---------------- ------ Disposal Field: Distance from nearest well-.- Distance from foundation__-149_----------.Distance to nearest lot line___________ ] Number of lines------1--------- Length of each line---- 0'7P- ____---_ Width of trench.--- _ `__---------------- Type of filter materia. 's__r (''__Depth of filter material------ /_ r_____.Total 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 from nearest well ___-- _-___Distance from foundation--------------------Lining material---------------------------.________- ❑ Size: Diameter- -- --------------- ----------------Depth--------------- ------------ -- - - --- --------Liquid Capacity---------------------------gals. Privy: Distance from nearest well______________________________________________ __Distance from nearest building.-____.___________________________-__---_. ❑ Distance to nearest lot line-- ------------------ -------------------------------------------------------- ----------------------------------- Remodeling and/or repairing (describe):-----a�_ fA _� -----_��f�•----- �'� 41� f-•-------------------------------------------------------- ------------------------ --- ---- -- --------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- 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. (Signed) ` r _____ --------!em__ _te_ _ :�_.------------- - -------------------------------------------------- ------------ -----Owner and/or Contractor By:----------------------------------------------------------------------------------------------------------------------------------(Title)------------------ -------- --------------- -- -------------- (Plot ---- - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---,l r x = = ---------- -- ---------------------------------------- DATE----4P___/Z_-<1� ------------ ---------------- REVIEWEDBY--------------------------------------------- ----- ------ --------- - - --------------------------------- ------------------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------ ---------------------------------------------------- DATE------ ----------------------- ------------------------------ Alterationsand/or recommendations------------------ -----------------------------------------------------------------------------------------------------------•--- ---------------------- ------------- --------------------- -------------------------------------------------------------------------------------------------------------------- -------- - ---------------------------------------------------- ----------------------------------------------- -------------------------------------------------------------------- -- ---------- ----------------------------------------------------------------------------------------- ------------------------------------- ----- ---- -------------------------- -- ------ FINAL INSPECTION BY:.... -.. ! ��---------�_-•......._-------,i------------ ---- - - Date-_.._ - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.C O.