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FPR OFFICE USE: - --------- APPLICATION FOR SANITATION PERMIT Permit No. .�.1..�/_ ---------- ----- ='---- --------------------------------- -- ---- (Complete in Duplicate) bate Issued - This Permit Expires I 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. 549. JOB ADDRESS A 4 LOCATION-- - ' rfy -------------------------------------------•---------- r Owner's Name - ..". -- f°' ------------------- Phone ----------------------•-------- Contractor's Name------- ----------- 7`S --------------------------------------------------------------------------- Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel El Other ❑ Number of living units: -___I.- Number of bedrooms .-"z" Number of baths _.P---- Lot size -_--------------------------_-------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _6P ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe e—Hardpan ❑ Previous Application Made: (If yes,date..--_._-_...--------) No Z-11, 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 k'.- Distance from nearest well----------------- .............Distance from foundationMaterial.........______--......----.._.------------_----- p& l No. of compartments-------------------------Size------------------ --------- ---Liquid depth---------------------- ---Capacity----------------------- t DispI Fie _ Distance from nearest well-_--------------Distance from foundation..._.--------------Distance to nearest lot line----------------- Number of lines--------------------------- ------Length of each line------------------------------Width of trench-------------- ------------- 6�� u} Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------ See ____------------ ------------__.._._Seepage it: Distance to nearest well-----_-_-------------Distance f om fou dation.., O---.._.._-_.Distance to nearest to linei�`� _ ------Linin material-- _Size: Diameter---+� .-----.-----Depth-- -- ---- ------------------ >E Number of pits---- ..-.-- g ------ Cesspool: Distance from nearest we]....--.--- 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. --------- ' } - 1 Remodeling and/or repairing (describe)=-- ----------------------------------------------------------------------- -------•--- -----------•------------------------------------------------------------------------------------------------------------------------------------- --------------------------------•----.....-------------------------------- - - ------------------'------------------------------------------- --------------------------------- 1 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. s (Signed) (Owner and/or Contractor) By:-------- -------- ----------------------- ----------------------------------------------------------------(Title)------------------ - -------+--------------------------------. (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.. ._. --------------------------------------------------------- DATE ---------------� - ------------------------------- REVIEWEDBY---------------------------------------------------------------------- ---- --- ------------------------------------- DATE---------------------------------------------- ------------- BUILDINGPERMIT ISSUED---------------------------- - � -------- ----------------------------------- DATE---------------------------------------------------------- Alterations and/or recommendations:..4+ ` / -%1 / -- ---------•----------------------------------------------••------------- -------•-•--------------------------•--------------------------------------------.----------------------------------------------------•-- ---------------------------------------------------------------------- ------------. --------------------- ------ ------ ----------------------------- --- ------------------------------------•------ FINAL INSPECTION BY: ` �� - Date. ........' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CG. Y