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FUKUFFILt USE: ---------------- - ---- ------------------------------- ----------------------------- ------------------------------__.................................... .... ............ APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicated Date issued - -------------------------------------------------------- This Permit Expires 1 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. 549. t s U A/. s�-��~.mss�� 1'-20 '. � - � � r JOB ADDRESS AND LOCATION_ �1- � ...... ice' ' ---- = g Owner's Name--�--7--'- `tet^ --1,�........ ---- ......... - . L /F, -_.�.-s.� ------. 1 • -;�---•-- =--�--= - -------------------- -- Phone-----•-----•--------•----- Addressf-- "'`------------- -------------------------- -'"---------•--------•----•-------•-----------------------•------- ----------------------•------------•-----------------------._.. Contractor's Name---- /V 22_, iir .,v- Phone...- -------------------------------------------------------------------------- ------- Installation will serve: Residence O� Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --I.---- Number of bedrooms -3---- Number of baths _f-__._ Lot size __--___________________________________ ---- Water Supply. Public system E] Community system ❑ Private hk Depth to Water Table _F.. ft. f Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam'Q Clay ❑ Adobe t2 Hardpan ❑ Previous Application Made: (If yes,date-------------------- No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: .-----,(No-septic-.tank-or-cesspool p4`)m—itted�if public-sewer-is=evailable-with 2oo--feet:_) _ -- Septic Tank: Distance from nearest well'--- _�_b- __.___Distance from foundation-_.-_- ---J-------.Material-_. _A-- I------I----- ¢___._ --------------- No. of compartments_.!A�----------------- --- /- - '---�.____Liquid depth........ -----------------Capacity__!_ -- --- --- Disposal Field: Distance from nearest well_._1..�!.....Distance from foundation---!_�_------------Distance to nearest lot line,_-y 1._----. N r Number of lines___X---- ______________________Length of each line---9-'g--------------------Width of trench---Z`t----- Type of filter material-W- -------------- of filter material ___ -------------Total length---``--_4_b--------.------------------ Seepage Pit: Dp Distance to _ t well____________________ Distance from foundation__......------------Distance to nearest lot line-----.----------- Number of its----------- ,Lining material-----------------------Size: Diameter-----------------------Depth-------------.------------------- Cesspool: Distance from nearest well---- .._--_Distance from foundation....................Lining material-----------------.------_.-------.-_-. ❑ Size: Diameter----- =- =Q. 4\.Depth----------------------------------------------------Liquid Capacity----------------------------gals. Priv Distance from newest well ____ ___ __"�"''__---._---_ Distance from nearest building g-----------•------------------------------ ❑ Distance to nearest lot line _ __�__I___F__..._t_ -------------------------------•---------------------------------- ------------------------------ Remodelingand/or repairing (describe):--------�=---- ---- --------- --- ------•----------------------------- ----------------------------- ------------ ----•------------------- --------------------------•-----------------------------------•-=----------- - ------------------------------------ ---------------------------------------;---------- -------- I -------------- --------------- - -- - -- - - -- -- - - - - -- -- --------------- -- - -- - -- ----- -- -- ---------------------------------- I hereby certify at I have prepered-ft"'al5plicatidn and that the work will be done in accordance with San Joaquin County ordinances, S to ws, and rules and'-t�ula 1 ns(of the San Joaquin Local Health Disfrief. a (Si ned -------- k ��j, = g ��------ --- 6'' r -- !f`` , ---------------------------- ------ -----------------(Owner and/or Contractor) --•------------ -----• ----- _ -------------- (Plot plan, showing size 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-A!.---/.( - r --- ------------------------------------------------- REVIEWEDBY------------------------------------- - -------------------------- ------------------------------------------------------ DATE------------ ---------------------------------------------- BUILDINGPERMITISSUED--•------------------------------- -------------------------•--------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations: ----------------------------------------------------------------•-------------... --------------------------------- ----------------------------------------------------------- ------------------------------------------ ----------------- -----------I----------- ------- ----- ----------------------------------------------- ----------------- ------------- •------------------ FINAL INSPECTION BY:... . ... ..... 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 t I