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�! OR OFFICE USE . 017 -------------------- - APPLICATION FOR SANITATION PERMIT Permit No. ------------------------- ----------- ----------------- ----------------------- - -------- (Complete in Duplicate) - This Permit Expires I 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.Zd ,_ JOB ADDRESS AND C TI N------ _.� '7 ef, -(/ 7`�'---------•-------------------- /� ------------- Phone------------------------------------ Name----- / -----------------------------.----- '• Owner's Name---- e,_A Address---------------------------- ___1? / 4-- /---��'- ------------------------------------------------------------------------------------•------------------------------------ Contractor's Name------ --------' ��_ ._-'" ---------------------------------- •------------------------------------ Phone----------------------------•------ Installation will serve: Residencepartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---- --- Number of bedrooms __umber of baths ,/__-_ Lot size -_;�6 -X---- -. -----•--------------- Water Supply: Public systemommunity system ❑ Private ❑ Depth to Water Table .g_3- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: (If yes,date--------------------) No New Construction: Yes ❑ No �A/VA: Yes ❑ No E�� 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---------------.--.__________________-____._-_-. N ❑ No. of compartments--------------------------Size--------------------------------Liquid depth---------- ----- ---------Capacity---------- ------ .J Disposal Field: Distance from nearest well-----------------Distance from foundation__________-_..-_.__Distance to nearest lot line_______________ � Ad Number of lines-----------------------------------Length of each line-----------------------------.Width of trench---------------------------------- Type of filter material-------------------------Depth of filter material-----------------------Total length_-_-____.___________--_________-�--__ Seepage it: Distance to nearest well from foundation_/0_�_.___.Distance to nearest lot li ^ __.�__________ , LV Number of pits____I--------------- Lining material_._ c?Pr ----Size: Diametey._ � ..__. Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_____.._______-_______._________.___ r' ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------------------------- from nearest building ❑ Distance to nearest lot line------------------------------ e -------------------------- ________________________� Remodeling and/or repairing (describe): -,!��1-- -- -��-.-L��------- ---------••---------------•-----------------------------------------------•--------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------ -----------------------------------------.----------------------------------•------•----------------------------------------------------------------------••--•------------------- I ------------------------------------------------------------------------------------------------------------------------------------••---------------------------------------------------•- ------------------------------ I hereby certify.t have pre this application and that the work will be done in accordance with San Joaquin County ordinances, Statefid rules,a re ns of the San Joaquin Local Health District. Si ned ------ -------------------------------------------------- L./ -.(Owner and/or Contractor) , By----------------•-----•------ ----- (Title) (Plot plan, showing size of t. I. cation of system in relation to wells, bull Ings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY r� �` _ APPLICATION ACCEPTED BY------- DATE 1� - � REVIEWEDBY--------•------------------------------------ ----- - ----- ----------------- ---------------- DATE----- ---------------------------- BUILDING PERMIT ISSUED----------------------------2 ----- � --------------- -------------------. DATE-------------------------------------- ---------------------- Alteratiortis and/or recommendations:___.__.-__--- -_�_______ -------- — ' >` ---�=-•-�------ ------------------------------ -------------------- -- -- ------------------------------------------------------------------ -----------------•-----------------•------------------------------------•----------------------------- ----------------------------- ----------------- ------------------------------------- ------- ---------- --------------------- --------------- ------------------- - -------------------------------------------------------------------------------------- ---------------------------------------------------------------- ----- ----------------------------- --------------- --------- Date f -•---------- -- -- FINAL INSPECTION BY:..__ /_��r.��__________________ SAN JOAQUIN LOCAL HEALTH DISTRICT 1661 E.Ha=elton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 6-59 3M 3-'S3 F.P.CD.