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FOR OFFICE USE: ---------------------- ----- ------- ---------------- -- -------------------- -------------------- - -------------------------------------------- ------------- APPLICATION FOR SANITATION PERMIT Permit No. ------------------------- ------- -------- (Comple+e•in Duplicate) ------------------ This Permit Expires I 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. JOS ADDRESS AND LOCATION__---.- --L�--j--- -3- ---- ( { � �,�7 1 ----------------------------- / Owner'sNa e_ ._C? �._C+� f�' - -- -C2- -------------------------- ------ --- -- ---------- ------ --------- -- - Phone__-.'. �__ #J s s -.....---I Address. •---- -------------------•---------------------------------------------------•---------------•----------- ------------------ Contractor's Name �� 3I�1--r-`� - � - �/CF Phone__`7`�-i�J(O~ ... ,! -- Installation will serve: Residence }K Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _�.-___ Number of bedrooms 3--_ Number of baths _Y__- Lot size - --•- r __ ------ - ---- Water Supply: Public system [I Community system ❑ Private ❑ Depth to Water Table _ eft Character of soil to a depth of 3 feet" Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date.....-__.___....... ) No ❑ New Construction: Yes ❑ NoFHA/VA: Yes ❑ No ❑ u TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 4 Septic Tank: Distance from nearest weil-................Distance from foundation- Material _______._____.._..-_ - . ----- ------ ❑ No. of compartments---- -------------------- Size-------------- -----------Liquid depth------ ......... .....—Capacity------ -------------•-- DispV. J Field: Distance from nearest well-!--- _. ._Distance fromfoundation--- -0__ -----.Distance to nearest lot li e__-.�- - Number of lines.!--- __ ______ _ Length of each line__. _ ___Q..-r.......__._.Width of trench.-_-e+�-!K .--- e f . Type of filter materia -�(.__._.Depth of filter materia____.� __.-_'__All Total length_-_-_.._________.._ __ f7 Seepage Pit: Distance to neares well_.. ._f - ...._-----Distanc from f ndation_-- © Dist ce to nearest lot line----- y i Number of its.- �,- p _.Lining material-- -- , � - Size: Diamefer_p,6..-r----Depth------ -------------- Cesspool- Distance from nelarest well ----------------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------ - PY ---------------------------------------------------------- Remodeling and/or repairing (describe)__________________ _____ ----------------------------------------- - _ ----------------------•---------------------------------- - -I------------ I -Az _____ __--• - -------"_ -- ---------- 7------------------------------------------------ --------------------- ---------- ------------------------------------------------- - ---------------------•---------------------------- ----------------------------- -------------- - ------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinanc , State laws, rules and reg0 ations of the San Joaqdin Local Health District" (Signed) ' Ai- " (� Contractor) i ----- - ---- -- Y• --------- Title}.......r . - ---------- (Plot plan, showing size of lot, location of system in relation t wells, buildings,' +c., can be placed on reverse side}. • i FOR DEPARTMENT USE ONLY' APPLICATION ACCEPTED BY---- ---- REVIEWED -•REVIEWED BY. .... ..---- .--- ----------------------------------- - -'--------- ----------- ------- --- DATE....------------ -- ------------------------------- BUILDING PERMIT ISSUED-------- -------- --------------------------- ---------- DATE-- ----------- ------------------------------------------- Aiterations and/or recommendations:-=-------.........I------------------------------- ---------- -------------------------------------• ------------------- --------------------------- ------------•-------------------------------------------- ------------ --------------•--------- --- - ----------• ---- ------------------------------------ ---------------------- ----------------------------------------------------- - --------- ---- ------------- -------- - I --------------- --- ---------- --•-------------- --------------- / 4 FINAL INSPECTION BY:. �. V._7� Date - -./ - 6� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street i Stockton,California Lodi, California Manteca,California Tracy,California E.H.9 2M 1-67 Vanguard Press