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NFOR OFFICE USE: ---------------- 0 .6 . •�/ ______________ APPLICATION FOR SANITATION PERMIT Permit No. .___l. d .---_ c ---------------------------- --------- ---- ------------- (Complete in Duplicate) 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. 54 . JOB ADDRESS AND LOCATI , -� Owner's Name ---•--- -----=------------------------------- ----------------------------------- ------ - Phone--.-..--------•----------------•--- h r. Address__._.. . _. - .•. _ --- ---------------------------------------------------------------------------'--------- ... .....------------------------------- Contractor's Name----------- ---------------------- Phone-----...------•----------- Installation will .serve: Residence ®"A-partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number`of living-units: __ __ Number of bedrooms A__ Number of baths - - Lot -_____________________________ Water Supply Public sysferii 2--Communify system ❑ Private ❑ Depth to Water Table 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-g?'- New Construction: Yes ❑ No [/ FHA/VA: Yes ❑ No �g-T TYPE OF INSTALLATION AND SPECIFICATIONS:- (No septic tank or cesspool permitted if public sewer is available'within 200 feet.) S!pfic,Tanl : Distance from nearest well-----------------Distance from foundation------------ ......Material----------------------------------- -------____.. y No. of compartments-_'----------- am artments:'____...._._ . .....Size.................. =.-Li uid'de th....___:_ __ .`_ 'C-a acit Disposal-Fiejd: Distance from nearest well------- -----Distance from foundation__,pZ60_/------Distance to nearest lot line_4----____-. Number of lines__.f_:_• �_____ Length of each line-4-Y-4 of trench_/__________.___..._____-_.-- + J ----- - 6< < Type of filter material', p _-__Depth of filter material.._.��_ .__Tota1 length___,Q_____________________--__-_ Seepage Pit: Distance to nearest well--------- fr m fo ndation_-- 0_.------.Distance to nearest lot line_ _'__.___._ --Number o pits-.-._`�..............Lining material_�D4ey.e....Size: Diameter_SI---- -- Cesspoo#: Distance/-om nearest well-----------------Distance from foundation....................Lining material----.------._______.._.____________- [] Size: Diameter------ ---------------- -------------Depth----------------------------------------------------Liquid Capacity---------------------------gals. , ^ Priv �_Nsfance from nearest well________________ _..Distance from nearest buildingv + ❑ Distance to nearest lot Iine------------------------------------------------------------------------------------------------ - ------------------------------------------ a, Remodeling and/or repairing (describe):--------- - --- [ -------- ------------ ------- -- ------------------------------------------------- � - -------- -------------------------------------- a --------------------------------------------------------------------------------------------------------------------------------------------------------------•------------------------------------------------ I 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 regulaf•ons of the San Joaquin Local Health District. (Signed)--------------------------------------------------- - `J --- --- -------------------------------- - -- f or Contractor) B (Title}-_.C � (Plot plan, showing size of lot, location of system in rela n to wells, buildings, etc., can be placed on reverse side). FOR&PARTMENT USE ONLY APPLICATION ACCEPTED BY. - ---- ------------------------- DATE----��_-�_/f_` --------------- _. .:_ __ - -- REVIEWED BY DATE-----' ATE ------- -------•---------------------------------------- BUILDING PERMIT ISSUED-------------------------- -------------------------- DATE------------------------------------------------------------ Alterations and/or recommendations:___f0/Gym/�f/_____ r___.. �L�� -� ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -----------------------------------------------------•----------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------- ---- - --- --------- ------------------ -------------------------------------------------------------------------------------------------------------------- ------------------------------------------ FINAL INSPECTION BY:.....��...... __.___. � .._ Date__.-� �- ----- ---------- -------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT - -^ S..•� .fit*o: k t 1661 E.Haz&14 Avi. 300 West Oak Street 124 Sycamore Street 4 205 West 9th Street Stockton,California Lodi,California Manteca, California Tracy, California F.P.c;0. l