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FOR OFFICE USE: --------------- ---- �- - ------t............. �---- APPLICATION FOR SANITATION PERMIT Permit No. ....... -------------------------------------------------------- (Complete in Duplicate) /d ------------------------------------------------------.,_.. This Permit Expires 1 Year From Date Issued- - DId ate Issued ___.___ �__6 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. JOB ADDRESS AND LOCATION______._ 1� _ _ - --------- i_, A6_ J Owner's Name-------------- Qf''_ _.......... -------------- - ---- - Phone-- - --- ------ ---------------------------- ----- -- ------------- ------------- -- - - Address__. I �.+ �--------� 4� �� Contractor's Name - - �L.�'-s;,-•------•--------------------------------- ---------------------------------------- Phone.. Installation will serve: Residence P" Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __I/__ Number of bedrooms____ Number of baths 1_____ Lot size ---- --------------------- Water -____________________ Water Supply: Public system ommunity system ❑ Private ❑ Depth to Water Table,-�Jb ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ San Loam ❑ Clay Loam ❑ Clay ❑ Adobe ar pan ❑ Previous Application Made: (If yes,date.....:----------___,l _.No. J Construction: Yes ❑ No FMA/VA: Yes ❑ No [ _� TYPE OF INSTALLATION AND SPECIFICATIONS: - (No septic tank or cesspool permitted if public sewer is available within 200 feet.) p _ -------Distance from foundation-�?-------------Material---------------------.---------••----- ........ Septic Tank: Distance mpm neenf�s eII 2---------Size--------------------------------Liquid depth--------------------------Capacity-..----.---------_---- �. Disposal Field: Diisstance from rnearest well-___ r._ ..,-. Distance from foundation___._____________.Distance to nearest lot line_________________ 4 // Number of lined------___________________________Len'gfih ofieach line-----------------------------.Width of trench-------------,_________._______.___ r Type of filter material-------------------------Depth of filter,material-__._._____...___..__Total length________________________________________ k A t Seepage t: Distanceto nearest ' ell-__-_Distance m foundation_/t--__-___ Distance to nearest lot lines_: Number. of pits- ___.______Lining material__ &JK---__Size: Diameter__ „-1--- -__Depth..�,�"_� �✓ `'�, Cesspool: Distance from nearest well-----------------Distance from foundation---,---------- ___Lining material____..._____._____..______.________- 6 ❑ ---Depth---------------------------- -----------------------Liquid Capacity---------- Size: Diameter :- ------- ---- gals. Priv Distance from nearest well___________________________ ______.___._Distance from nearest bui{din Privy: g------------------------------------------ ❑ Distance to nearest Pot lire--------------------------------------------------------------------------------------------------------------------------------------- i Remodeling and/or repairing (describe ------- ---- ---- ------------------------------------------------ ------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------- ------------------------------------•------------------------------------------------••-------------------------------------------------------------- - ------------------------- --------------------------------------- -----------------------•-------= rK 1 �r I hereby certify that-];-have prepared thism.application and that the work-will-be,doneTin-accordance•with San Joaquin County fi ordinances, State laws rule eguiations of the San Joaquin Local Health District. ----------------------------------------- ----Owner and/or Contractor (Signed)----------------- -- - -------- ------------>---- -- -- -- - ( / ) By--------------------------- --- - ---------------------------------------------------�J(Title)= ..._....._...._..._. ...... (Plot plan, showing size; of, location of-system-in.reiation�to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_____________ __ DATE_______1 __ _.._ l ____-_________.__..._ REVIEWEDBY---- ------------------------------------ - ---------------------------------------------------------------------------•--- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED-------------------------------------------------------------------------------- ----------------- DATE----------------------------------------------------•- ' Alt rat' ns and/or r commendations_________________________ . --------------- ------------------------ ------------------------------------------------------------------- •--•---------------------------------------------------------------------------------------------- FINAL INSPECTION BY:_..._._.__r. w - Date_____ -14 �f -------------------- �T-- -------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 134 Sycamore Street 205 West 9�th Street -ati' "ate Lodik Californ al. ` � % #y. �"'-.r Stockton,California Manteca,Californi Trac`,California € F.P.C C. 1 1 _ 1