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FO ,R OFFICE USE: 1 E i ------------------------------------------ - APPLICATION FOR SANITATION PERMIT Permit No. .... --------------------------------------------------------- (Complete in Duplicate) This Permit Expires 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. This application is made in compliance with County Ordinance o. 549. .p I JOB ADDRESS AND LCOTION------ - -- ---------'51:7 �/-- n-&-/ ---- f-------- .---------•---------- Owner's Name----------------• v�p---- ----------------------- / __-- �A � � ddress--------------------- - -------7----------... ,T ---------- ---------- --------P--h--o--n--e----_----�--- ----------- Contractor's Contractor's Name------ , � ------ ------------------- ----- Installation will serve: Residence [t�/partment House ❑ Commercial (] Trailer Court ❑ Motel ❑ Qther ❑ Number of living units: --/--- Number of bedrooms --- Number of baths ---/-- Lot size --_1490,w_ X-_5^----------------------- Water Supply: Public system ❑ Community system ❑ Private �epth to Water Table ------.- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date---.-.--------- ....I No [ ' New Construction: Yes ❑ No P— FHA/VA: Yes ❑ No 1-- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest weU-----------------Distance from foundation--------------------Materia4-------------------------------------.----------. ❑ No. of compartments--------------------------Size------ -------- ------Liquid depth--------------------------Capacity-••-------------------- Disposal Field: Distance from nearest well---s�_0_.__Distance from foundation-�.--------.Distance to nearest lot [ Number of lines---------. _- -- - --Length of each line --"--zs r-_;!-..5CVidth of trench----- --------------- N l Type of filter material --� 10081 1e_Depth of filter material-!*--------------Total ---------.------- r. Seepage Pit: Distance to nearest well------------ ------Distance from foundation--------------------Distance to nearest lot line-----..---------- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------DepA--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation......------.------.Lining material_-.--------------------.------------- El Size: Diameter-------------------------------------Depth---------------------------- ----------------------Liquid Capacity---------------------------gals. IfI Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----.----------.------------- ----- I ❑ Distance to nearest lot line----------------------------------------------------------------------- ------------------�------------------------------------- +I Remodeling and/or repairing (describe):--_* a l ----------- 1 j-,S' 1.�Y ---•,.�� / •tJY---.-.•---------------------- -------------------•--•--------•----------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State rules and regulations of the San Joaquin Local Health District. (Si neo r9,�. Vis__ . .. --.�1/�--------------------------- 9 ) Wand/or Contractor] By:-------------- �� (Title} - , (Plot plan, showing size of lot, locati n of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED -----------------------------_---___ f ----------------------- DATE-----,'l�__w.'_1-.�---fes-5------- ----------------- REVIEWEDBY--------------------------------------------- -------------------- -------- -------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------ ---------- DATE.----------------------------- ----------- -------------- -- Alterations and/or recommendations:---------- --------------------------------------------------------------------------------------------------------------------------------------------------. --------------------------------------------------------------------------- ---------------------------------- --- - --------- ------------------------ ---------------------------------------------- --- ---------- FINAL INSPECTION BY:.. '1 �=`'L Date_- �� - -C'----- -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.ffa:eiton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodir California Manteca,California Tracy,California F.P.CC. { I - .