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f_, f OR OFFICE USE: �a �� . 7 �. ., ------------------- L �r_s_- _ ___ -.-- APPLICATION FOR SANITATION PERMIT Permit No. .11f ----------------------------- ------- ----------------- (Complete in Duplicate) Date Issued __,111 ----------------------------- --- 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. 25 C, JOB ADDRESS AND LOCATION....----- Q '-----------w `--------_ - ------------ oi�T--------------------------------------- Owner's Name --- ------------------------------------- Phone ------ Owner's Name -• '•---- ----� --- - ---------------------------- � Contractor's Name----------- ---•-•------------- Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __J----- Number of bedrooms --!=Number of baths _--- -- Lot size --------- r--X.rte_--_--------=--------- . Water Supply: Public system 9Community system ❑ Private ❑ Depth to Wafer Table Alin ft. Character of soil to a depth of-3 fee+: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe X Hardpan ❑ Previous Application Made: (If yes,date-----------....... .) No 7t New Construction: Yes ❑ No W FHA/VA: Yes ❑ No y TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T4k:, Distance from nearest well__.._-- ---___Distance from foundation--------------------Material_________._.__'_.______..____------:--__----- ❑ No. of compartments_-- 7n---- -----------Size--------------------- t----Liquid depth--------------------------Capacity...---- --------------- DisposalField Distance from nearest well' te__.Distance from foundation_____ ........Distance to nearest lot line___(------- Number of lines---------1---------- ...........Length of each line-----------70_..._______ Width of french----------- - _4--_----_.-- Type of filter maferial-__s._' ° _—Depth of fi{ter material___-____� _.`.'--Total length-------------------- �_.________._ { ---- �__.-___.Distance to nearest lot line..._________---- ' Seepage ��rt: Distance to nearest well__ ________________ Distance from foundation______ _:Gi � Number of pits.-------/-------- g - ------------ 43'-4' Depth ?.-s] ' kinin matenal�^_ �� Size: Diameter______ -_ Cesspool: Distance from nearest-well-----------------Distance from foundation---------------___ Lining material------------------------------_______ ❑ Size: Diameter------------------------- - ----------Depth---------------'--------t------ ------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well......... -------------------------Distance from nearest building i ❑ Distance to nearest lot line--------------- '------ --- --- - -- --------------------------------------- -------------------------------------•--------------;-------- r f Remodeling and/or repairing (describe):-------- : ------------------------------------------------------------------------------•--;------------- --------•------------------------------------------------------------------------------------------------------------------- + ! hereby cer+ify 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./17 - -- ---------------------(Owner and/or Contractotj (Signed)----------Woo ---- ---Title (Plot plan, sho , of system in ation to wells, buildings, etc., can be placed on reverse side}. t .. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- -------- DATE - t REVIEWEDBY---------------------------------------------------------------------- 5 ----------------- ----------------------------- DATE------------ ------------------------------------------ BUILDING PERMIT ISSUED------------------------------- = - �/ ._ DATE------------------------------------------------------------ Alterations and/or recommendations:-,__ ` !�'G' �' ' ' �� -�=-`-V---------------------------------------------------------------•------------ ----------------------------------------------------------"------------------------- ---------- ------------------------------------------- ----------------------------------------•-------------------------------------- I ----------------------------------- ----------------------------------------------------------- = ------------------------------------------------•------------------------------------------------ ------------------------------------- -- ------------- ------------------------ -------------------------'-------------------------------- -------' -------------------------------------------------------------------- t 4 j - --------------------------------------------------------------------------- ------ -----...--------------'----•----'---------------------------•-•-----------------------------------------'--'----'---'-------------"- 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 .moi