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FOR OFFICE USE: ` ., _2:'Aj----------------------------- rl�IGS, / 742, ___ ___ . APPLICATION FOR SANITATION PERMIT Permit No. .1.... ............ -------- -------- ----- --- 'n '------- (Complete 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. 544. JOB ADDRESS AND L CATION__ ' . �l rud---------Owner's Name---------- - - -•-------- -v I-Y-)-ij--A.)----------•-------------- - ------------------ ----------------- - Phone-------------------------------••--- Address = -- ----- -- --f--- - ! ' < 1 1 Contractor's Name _ ---- ------------------------------------ ----- ----------------- Phone---- Installation will serve: Residence + Apartment House ❑ Commercial ❑ Trailer Court ❑ Mo 1 ,.--Other ❑ Number of living units: __1-_-_ Number of bedrooms _-_ Number of baths _ __ Lot size ------ _6------------------ Water Supply: Public system Community system ElPrivate F-] Depth to Water Table6� ft. i Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑:Adobe Hardpan ❑ Previous Application Made: (If yes,date-_---- . _--_--I No �ew Construction: Yes ❑ No P_-'SHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: t (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation_______________"`-Material___'_----_-------_._____--_-________-._________- V;I No. of cornpartmeats--------------------------Size--------------------------------Liquid depth---------- -------------- -- ---------Capacity------ -------------- Disposal Field: Distance from nearest well___—._-_Distance from foundation__ JD Distance to nearest lot line___�___�____ Number of lines___--_ l _ Length of each line______ Q Width of trench______�V_F_______----._-_� ---- ,- �1 filter material__!/1_ _Depth of filter material___ r1__-,--------Total leng#h___�jl_1------------------------ Type,-of .—• l Seepage P Distance to nearest well------- - -----Distance rom foundation_--w_-__-___ Distance to nearest lot line__-_'R_._J Number*,of its---.__�_-------------Linin material_ 0i�.. _ Size: tANIOV4 }Distance,from nearest well_________________Distance from foundation.__-----------------Lining material----._.-.----------------------------.V% ❑ ISize: Diameter_________________---------------------Depth ----_------------- ____________Luid Capacity-...-----------------------gals, Privy: Distance from nearest well-------------------------------------------- from nearest building-----______---------..___________---.____V ❑ Distance to nearest lot lire--------------------------- ---------------'-----•--------------------------- ------------------- ----------------------------------------•------ Remodelin9 and/or re air;ng (describe)_______________ -- - -•------•------------------ ---------__-_____---____---- •Viri`. `_._.. - --••-----------•----------------------------------------------------------------------------------------------------------------------- - ------------ --------------------------------------------------- . ------------------------------------- ----------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------- I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and reguia+io s of +he San Joa in Local Health District. , (Signed) - -- --- ----- r (Owner and/or Contractor) j , By:------------------------------------------------------------------ ------- --------- --- `--------(Ti+le) - A- ... - ----------- -------- ---- -------- (Plot plan, showing size of lot, location of system in relation wells, buildings, etc., can be placed �on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- --------------- ---- ----------------------------------- DATE-----` 7' -60 ----- ------------ REVIEWEDBY----- - ------------------------------------- ------ DATE-------------------------------------- --------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------ ------------------------------ Alterations and/or reccem da+ions:----------------------------------------------------------------------------------- --------•-•-------•-----. ---------------•---•---------------- -- -- ---------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------- - ------------------------------------------- ------------------------------------------------------------------------------------- ----------------------------------------- .- ---- FINAL INSPECTION BY:--------- ----------------------- ------------- --- Date-_..-.-._ SAN-JOAQUIN LOCAL HEALTH DISTRICT w—w0661 E.Haiellon Ave- 300 West Oak Street , 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.M. + -