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FOR OFFICE USE: O ti --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. au-J�j - - (Complete in Duplicate) C - Date issued --------------------------------------------------- -- This Permit Expires 1. Year From Date Issued Application is hereby made to the San Joaquin Local Health Di"strict for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549, JOB ADDRESS AND OC. N --- 'rc"'� ` ✓__ _ �� -- ------- Owner's Name- -- - - - ----- ----tq_ /-"' :_ _�_q -- �_ pjv�.r Phon _ _ ,_ ; t Address = .......—e - --------------- � ~ ........t t Contractor's Nam �, /____ __ 1`'!.� _____ Phone-- __ Installation will serve: Residence p]----Xp-artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ms�ss-----�- - - ,r Number of living units: _/____ Number of bedrooms Number of baths _ -___:_ Lot size .�2_ __l _/.. -____._—-------------- Water Supply: Public system ommunity system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ I Previous Application Made: (if yes,date--------------------) No ❑ New Construction: Yes ❑ NoHA/VA: Yes ❑ No ❑ 1 TYPE OF INSTALLATION AND SPECIFICATIONS: l # Y(No septic tank or cesspool permitted if public sewer is available within 200 feet.) o Se Distance from nearest well_________________Distance from foundation-------------------.Material.------------- -------------______-__-__________- "'� No. of compartments- — -----------Size--------------------------------Liquid depth-------------------------.Capacity__--------------------- yi s Distance from nearest well.4'�L��Distance`fCom-foundation__ le .i to nearest lot line-J-7/.- Numb ine__--r-_ � q Number of line------- __ i;-- _ Len th of each line-.= 1-------------Width of trench �/ Type of filter materia ---Depth of filter material..:._/-__ _- Total length____________________amu_ -___---__-- $eepar ePit: Distance to nearest well _ __-_-_-___Distance rom foundation-----/C -------Distance,to nearest lot line- Number of pits---I__________________Lining material_ -_ b-.0 __-.Size: Diameter "_"/__ _.-"`__Depth.............tY- ----------- n } L' r I a � - ` U I Cesspool: Distance from nearest well_______-_-----__Distance from undation___________________`Lining material________------.----------_-__-_-____ ❑` Size: Diameter----- -----'----- --- ----- I------- Deptl? = '?--------------------------------------------Liquid Capacity----------------------------gals. . Privy:; Distance from nearest well---------------------_--------.------------------Distance from nearest building__.---------------------------.__-___---_. T�❑? - �,. Dista rice to nearest lot line =------- ----- - --------- - -------- - --------- - -- - ------- Remodeling and/or repairing (describe):_--_:__--_-___ __ ' __ _ -- ---------------------------------------------------------------------- ------ --- ----- F -- --- ---< •�-L---------------------------------- + ----------------------------------------- ------------------ --------- ------ --- ------------ ------------------ ----- ---------------------------------------------------------------------- l 1 --------------- - ------------ -----------------------•--------------------------------------------------------------------- -- --- ------- --------------------------------------------------- --------- t I'hereby certify that I have prepared this application and-Aat the work will be done in accordance with San Joaquin County ordinances, St a ws, nd ules and re.gula ions,of the San acluin Local. /ealth trict. ; 4 Si ned .- 1 By:---------------- ------------------------------------------------ --------------- � -- --- -- -- ----------(Title)--- --- -------------------- -- ------------------- (Plot plan, showing size of !o}, location of system in relatio o wells, buildi s, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--!$7!e- --- ---------------------------- -- ---------------------------------------- DATE----- ------------- -- REVIEWEDBY--------------------------- ----------------- --------------------------------------------------- --------------------------- DATE------------------------------------------------------ - --- BUILDING PERMIT ISSUED-------------------------------------- ------------------------ DATE----------------- , -i-------------- Alterations and/or recommendations:/ .7: ."(o ----- 1 ..... ' ----------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------- - ----------- -- --------------------------------------------:------------------ ----------------------- --------------- -----------------------------------------------------------------------------I--------------------------------------------------------------------------- -------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:.-W- - 4- ------------------------------ Date_ ---- - - ----- ------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ha:ellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi, California Manteca, California Tracy,California F.P.CO. 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