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,FOROFFICE USE: 3 - l ------- 9 APPLICATION FOR SANITATION PERMIT Permit No. _2 ----------------- ----- ---- ----------- -------------- - ------. .-- (Complete in Duplicate) bate Issued _JA�� .-_------_--_---__-- This Permit Expires 1 Year From 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. S49, JOB ADDRESS AND OCA 10 �3_ - ____ __x_7 ' - - Owner's Name---------- ----•-�--- --------------------------------------•--•---•--------- ------------------------------------------- . Phone--------------=--------------- Address -'------------------ ------------------------------------------------------------- ----------------------------- r lContractor's Name- -- ---- -------------------------------------------------------- -------------------------------------------- Phone-•---------••-----•---------------- f Installation will serve: Residence 0– Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -_1____ Number of bedrooms __v2_ Number of baths _/---- Lot size __j6O0CY09 Water Supply: Public system [n<ommunity system 0 Private M Depth to Water Table_ ft. II Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe M--Hardpan ❑ Previous Application Made: (If yes,date____________________) No New Construction: Yes k:� 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- o_-�--_.____.Mat rial_____-� No. of compartments_._.;Z__________________Size_____�_ tT` ------Liquid depth____. _9..___.______Capacity ----- __ Q fl Disposal Field: Distance from nearest well____:.~_.__._-Distance from foundation___0-------------- to nearest lot i ❑� Number of lines-----I---------------------------Length of,each linej�,O-----------------------Width of trench---- - -.---------------__.-- Type of filter material-_�ta-fv-k-.-----Depth of filter material---/._t4'__...........Total length--------59P--- ________-__ Seepage Pit: Distance to nearest well----__________........Distancp4om foundation---l6____f___--_ Distance to nearest lot line- .-_----_____ Number of pits_____I---------------Lining material"_1C4D__._CA[_____Size: Diameter...A7 Depth____ —-----___--_.__ Cesspool: Distance from nearest well-------------- Distance from foundation---------------.---.Lining r material----__._________----____..___._______- ❑ Size: Diameter--------------------------- ----------Depth---------------------------------------------------Liquid Capacity----------------------------gals. ' Privy: Distance from nearest weEI_---------------------------------_--------------Distance from nearest building---------------.------------_---- ----_- ❑ Distance to nearest lot line------------------------------------------------•------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe)--------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------- ---------------- ----------- --- ----------------------------------------------------- ---------------------------------------------------------------- ------------------------=------------------------------------ I hereby certify that I have prepare this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and r I ns of A an Joaqui Local Health District. (Signed) ___Owner and/or Contractor By:---- ••---------------------------------------•----------------------------------- ------ ----------------------------------------(Title)------ --- -------------------- -------.---- (Plot plait, 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-- = --------------------- -- --------------------------------- ----- DATE-----_` � 6- _(e-6------- ------------------- REVIEWED BY------------------------------------------------------------- ------ --------------------------- -------------------- ----- DATE--------------- ----•--------------------------------------- BUILDINGPERMIT ISSUED-- ----------- -----------------------------------------------------------'--------------------------- DATE--- --------------------------------------------------------- Alterations and/or recommendations---- ------------------------------------------- -------- ----------------------------------------•----•------------------------------------------ ------------ -------------------------------•-------- ----------------------------- -------------------------------------- ------------------------------------•-------------------------------------------------------------------------- --------------------------------------------------------------------- -------------------------=--------------------------------------------------------=-------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------- FINAL INSPECTION --- ---- - ----------------r Date---....X-14_"4.64-------------------__----------------------------- 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 E � I