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FOR OFFICE USE:----------------------------------------------------- G - --------------------------------------------------------- APPLICATION FOR4 SANITATION PERMIT Permit No. gz ..F.o._._ ----------------------- ------------------------------- (Complete in Duplicate) iSr - (Comlicate) Date Issued .__G_-.`___��.� ------------.---------------------------------------,___ This Permit Expires_? 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. 5549. / JOB ADDRESS AND LOCATI N ---------- -------s�. le- �-----.� _LLw --------------------------------------- Owner's Name------------ ------------- -- = -------- Phone Address----------------- - f 2----------4 � f ---- ------------------------------------------• ------•---------------- - ---------------------- - - Contractor's Name----------------- ------ Phone----.-.----------- Installation will serve: Residence T-_Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __.k Number of bedrooms __--2-Number of baths _f---- Lot size --________________-___•_-.-___________----._____________-_ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: (If yes,date------------------ ) No ❑ N4PW-Const.ruction: Yes ❑ No SHA/VA: Yes Eji No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) f� // Septic Tank: Distance .from nearest well-----`-q sx—weor foundation__ _.__Material_1e4Vt�'_W �____________________ ; � %��5 No. of compartments _ __________________ ize____ - Liquid de th____-_____..____._ _______Capacity 11 P ------ 9 R ---- -------- Disposal Field: Distance from nearest well-----------------Distance from foundation.-------------------Distance to nearest lot line----------------- Gj �r'cr f Number of lines___________________________________Length of each line------------------------------ of trench------.-------_-_____.._._._____._ Type of filter, material-------------------------Depth of filter material------------ .--------Total length-----------------_-------------.---------- Seepage Pit: Distance to nearest well----------------------Distance from foundation---------------.___.Distance to nearest lot line----------------- k1 , ❑ Number of pits---------------------Lining material---------------------.Size: Diameter.-----------..---------Depth---------------------------------- . Cesspool: Distance from nearest 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-i---- --- -----------------------°---------------------------------------------------------------------------------------- ---------------- Remod - ------- ---- -- g and or re airing Idescribe):__ � - - -- ---------------- -------------•---- ---------- ---- ----- '��f ,6�-� ------------------------------------------------------- ------ -------------------------=----------- I hereby cer0 at I have prepared this application and th the work will be done in accordance with San Joaquin County ordinances, State w and rules d regulations of the San Joaquin Local Health District. (Signed)..-- ----- ----- - '- ------------------------------------------------ - ------------------------- (Owner and/or Contractor) J - I /`.� ----- (Title)---� .f!�J ---- (Plot plan, showin si a 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------------- Z�c5,afG' ------------- REVIEWEDBY------ ----------------------------- ------------------------ ------ -------------------------• ----------------- DATE---------- --------------------------_-------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------- ------ DATE------ ------------------------------------------------------ Alterationsand/or recommendations:------ --- ------------ ---------------------- ----------------------- --------------------- ------------•--------- ----•----------------------•---------- . - FINAL INSPECTION BY:,` Date.------. ---------------- -------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT l 1601 E.Hozellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street + Stockton,California Lodi,California Manteca,California Tracy,California F.P.CO.