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r FOR OFFICE USE: 4b IL 43,_- Z ..................... . APPLICATION FOR SANITATION PERMIT Permit No. --------------- ----- __---- --------- (Complete-in Duplicate) I ------------------ - ------- -------------- This Permit Expires 1 Year From Date Issued Date Issued f 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 Al'A �---- -----------------" Owner's Name : ''!'� -------- ---•---------------------- ------------- ----.._- Phone------ ----------------------------- Address----------4,-------- - - ►..� ...-. Contractor's Name------ -- ----------------------------------- ------- ----------------------------------------------- Phone.----- -----•---------------------- Installation will serve: Residence* Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ----- Number of bedrooms --- Number of baths"-1------ Lot size ----- -- - -- ---_.-. Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table ------ - ft I Character of soil to a depth of 3 feet- Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan C❑ Previous Application Made: (If yes,date-. ....... ) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic +ank.or.cesspool-permitted if public sewer is available within 200 feet.) + Septic Tank: Distance from nearest well- .-----Distance Ze3 t from fndati�9� epth_(�Material jty _.-- _-.--. I No. of compartments--� ----- ---- ----- g - f�s9-- i I Disposal Field: Distance from nearest well-/.7_-----Distance from'foundat' n- .__---..-.Distance to nearest lot line--S`� -----. Number of lines._ /- I� ;�"-------- ----�-� -----�-Length of each line_,;#0._.... ............------------Width of trench .-�� -------------- ------�- Type of filter materiaAA'----------_.__.Depth of filter material---1g`'--_- -_-._.Total length- '----------------------------- l l Seepage Pit: Distance to nearest well-.--.--------------------Distance from foundation_------------------Distance to nearest lot line__.------.--- ❑ Number of pits.--I------------------Lining material-------..----------- Size: Diameter--------------------- Dept h--------------------------------- I Cesspool: Distance from nearest well ----------------Distance from foundation----------------- ..Lining material------.----_---______--.------------. ❑ Size: Diameter I ------- ----- ---------------Depth r Liquid Capacity gals. Privy: Distance from nearest well-------------------__-_.-__---._..--------- -.-Distance from nearest building--------------------------------------- ❑ Distance to nearest lot line _____---------------------------------- l Remodeling and/or repairing �descri'e�c----Cv. t' .R.tiC.rtx}-_- - ?/��:— - - ----------- ------_ --•--------------------------------------------- ---- ---------------"--------------------------------•------------------------------------------------------------------------------------------------ - i -----•--••----------- -- - -------------------------- ------••-•--------•--------------------=------------------------------------------------- -------------------------------------------------- ---------- -- - i ---------------------- -- ---------------------------I---------------------------------------------------------------------------------------------------------- ---- ----------------------- 1 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. �Si ned 9 )•-=---��- �- ---D`'-�- �.------------------.- --------- --------------------6---------- - --------------------(Owner and/or Contractor) i ------ -- --- �_ ...�,.a-t,...$y --------• - ----------...-..---• - ------------------------ - ----- --------__ ------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). r r t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTEDDATI -lir"- REVIEWEDBY----- ---------- -------------------------- --- ---------------------------------------------------------------- --• DATE BUILDINGPERMIT ISSUED-------- -- ---------------------- --- ---- --------------- ---------------- DATE------------------- ------------------------------------- - - Altera+ions and/or recommendations----------------------- --------- - ------ -- ---- -----•--------------------------------------------- - ----------- ... ----- ------- -- -•-- --- ------ -- ---------- .--.--- ----------------------- --------------------------------- --------------------- ----------------------•--------------- ------------- ------ ------------------------------ -- -- -•------ ------ ----------- ----- FINAL INSPECTIONBY:- ------ Date - . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore street 205 West 9th Street Stockton,California Lodi. California Manteca,California Tracy,California E.H.9 2M 1-67 Vanguard Press f . y