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FOROFFICE USE: --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. -.1T1 ---------------------------- ------ (Complete in Duplicate) ------------------ This Permit Expires 1 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. 549. k ;S'1` JOB ADDRESS AN ,CATI N_I _ _lh-r�L✓ y ---------------••------------------------------------------------------- -------------- flq Owner's Name------------- ---------------- ------- -------------------- Phone-------------- ------------------- Address �� ' r ------------- `�7 . ..... Contractor's Name------ - .- -- -------;-------- ------ --- ------ -- ------------------- Phone------..------•---•----••---------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __- - Number of bedrooms _3-_ Number of baths ___YLot size ____.��e—a+ __---------_______ Water Supply: Public system ❑ Community system ❑ Private [`Depth Water Table -------- ft. O Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [Clay Loam ❑ Clay ❑ Adobe ❑ 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 permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material—---______-____-___-.-_____--___-___.- ❑ No, of compartments-------------- ----------Size---------------•------------ ---Liquid depth--------------------------Capacity--•-------------------- r Disposal eld: Distance from nearest weft .-._Distance from foundation.---l_17_--_f___--_Distance to nearest lot line__T 01-------- Number of lines--------/-------------------------Length of each line----L-P.Q_--r_________-----Width of trench---`.+--- -----.------------------ Type of filter material_______;E ;vR_________Depth of filter material------t_q........... length___. t7t?-------------------------- Seepage Pit: Distance to nearest well----- ----------------Distance from foundation--------.----------.Distance to nearest lot line----------------- 0 Number of pits----------------------Lining material-----------------------Size: Diameter------_------- ------- Depth---------------------------_-_---. Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--.---------------------------_______- Size: Diameter-------------------------------------Depth----- ----------------------------------------------Liquid Capacity als. 4' Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---------------------------------------... ❑ Distance to nearest lot line--------------------------------- / Remodeling and/or repairing (describe):---------------- ----------- •-- ------•----------------------------------------------------- --------------------•----------------------------------------------- -��-- --------- --- D ----------- -- ---------------------------------------------------------------- - ------------------------------------ ----------------------------------------------- ---------------------------- ------- -----------------------------------------------------------------------------------------------------------------------------------------------•---------------------------------------- I hereby c rtify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St tlaws, and rules and regulations of the San Joaquin Local Health District. d 1 (Signed)------ ------- ---------- ----- --- - ----- -------------------------------------------------------------------------------------------- or Contractor) By:- •--- •----------------- -- ----------- -------------------------------------�--- ------(Title)-------------- ---------- -------- -- _._... --- - (Plot plan, showing size of lot, location of sys em in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED DATE__ `fv3_'GC- --------------------- --- REVIEWEDBY--------------------------------------------- -------------- --------------------------------------------------------- ---- DATE---------------- BUILDING PERMIT ISSUED-------------------------------------- -------------------------------------------------------------._ DATE Alterations and/or recommendations-------------------------------------- --- -----------------------------------------------•----•-------------------------------- -------------------------------•--------------------•----------------------------------------------- ---------------------------------------------------------------------•--------------------------------------------------- --------------------------L--------------A--------------------------------- --------------------------------------------------------------------------------------------------- - ----- - ----------------------------------------------------------------•------------------------------------- ---------------------L---- ----- --- -----------------------------------------•------ --------------------------------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:..r,> ''! - _,_r .- -------- Date- –6/1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California