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FOROFFICE USE: ,—�-- r �0------------- ------ -- s APPLICATION FOR SANITATION PERMIT Permit No. ------ ------ ------- ------------------ ---------------------------. (Complete in Duplicate). ----------------- --------- This Permit-Ex ires 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 No. 549. �J x JOB ADDRESS AND LOCATfON__. . .. '7 _ _ _ -- S f A Owner's Name -'.5 ._ ,----------- �~ --- ---- Phone. D: 9.7f------- Address 3---•---- K.. %? �------------- /� d ---�Ufi_j-----• -------- ------------•--------------•---•_...._..---:..-- --.....----•-•- Contractor's Name '. ._S.S_.,__. {` ., ------ Phone--_00�IAVL Installation will serve: j Residence �� Apartment House ❑ Commercial ❑ Trailer Court [I Motel E] Other E] Number of living units: __/-___ Number of bedroom_ s _��,_ Nu_mber..of baths ___/___ Lot size ____ --- T Water -Supply: Public.-system E�r'Community system ❑ Private ❑ Depth to Water Table Character of sail to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam E❑ Clay ❑ Adobe GR--Hardpan [❑ Previous Application Made: (If yes,dafe----------------- No New Construction: Yes :E] Na 2---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-------------------Material________-__._._________._---________.___-____._. F1No. of compartments_,--------- Size--------------- ---- ----------Liquid depth---------------------------Capacity - ; -_ ._: == =4 Disposal Field: Distance from nearest well-----------------Distance from foundation____:_:..-----------Distance to nearest lot line______ ❑ Number of lines ----- '---------------------_Length of each line---------- ---------------Width of trench r Type .of filter material_ ______________ Depth of fiitei material-----------------= `Total length_-----------------.-.---___-:------------- Seepage Pit: Distance to nearest well.71_�-�__Distance�ffrom,.fQ'��undation_____�: -- _:_.Distance to nearest lot line.... Number of pits-_.F----- -- --------Lining material___1_ .. {{ Size: Diameter------ -- ------Depth-------------- `�- ------ i Cesspool: Distance from nearest well_________________Distance from-foundation_-------------'_Lining'material_.___--_______---____- ' ------------ a ❑ Size: Diameter-__--________ � + Depth Liquid tCapacity ------------gals. Privy: _ Distance from nearest y ell__________---------------------------------------Distance from nearest building El 7 Distance to nearest lot'line.....---------------------- r i , t ----------------------------- ------- Remodeling-and/or repairing (describe):____`----. ,__t ------�----- ., - --- -- r - -• ------------------------------- - ------ ------------------------------------- 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. (Signed)----•------Q ,_�- -----,� -- ----- I ,;. � - ------�'-- �--- --- - ---- ----------------------------------------(Owner and/or Contractor) By: 1 O+ .. ' = # ------------(r+leJ ............. (Plot plan; showing size af_lot, Iota+ion f system in relation to wells, buildings, etc., can be placed on reverse side). } FOR DEPARTMENT USE ONLY t APPLICATION ACCEPTED BY____ ---------_-- r } ��' . :----------- DATE__ ,. REVIEWED BY------- ----------------------------- --- ----------- - l I DATE-- •----------------•-- BUILDING PERMIT ISSUED------_------ -11 - ATE 4 ------•. - --- D _ # A Cera+ions and/or recommendations:.--___-.------ -------------------------- _.�_.� ._---------�_---.-.---_•- -- --- ----- ------- ,- 'C .--------- -�-�` ...... 1p----- ------ .- _ _, ---•------------------------------- --------------- '` --------------- �.�_� -- _3.--- - � z ------ ----- ; FINAL INSPECTION BY:....... _C }_A� .fes 4----------------------- . ) -_ Date...... •, ._- x 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 Es 9 REVISE[] B-69 3M 3-163 f.P.CO.