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FOR OFF USE APPLICATION FOR SANITATION PERMIT Permi+No. ............. ------- ---`f p ---------- - -- -- (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 Ordinanc No. 549. _ 1_ �_ ----------------••--•-----------•-------------------------------•------- JOB ADDRESS AND LOCATI N__. _____ Owner's Name _ - - ----------------------------------------------•----------- Phone Address----------�T D ! ---• - , - --------------------•-•------------------------•---------------------------------------•------•--•------•-•-------------------- Contractor's Name ------------- -•--..__ Phone.------•----------------•----.----- Installation will serve: Residence 2'0`Aparfinent House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ ___ Number of bedrooms S__ Number of baths .Z__ Lot size �+r--�_f3Q...______________________________ p f Water Supply: Public system Community system El Private E] Depth to Water Table A__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobeardpan ❑ Previous Application Made: [If yes,date------_-------------l No New.Constructon: .Yes_[4-' o ❑ FHA/VA: Yes [ o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: - sem (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well___'"'___Distance from foundation----4�7--------Maters I_ ®� No. of compartments----_.�__r--------------_Sizerlp___✓ ___ ___Liquid depth_--.O�/O_--------_----Capacity...A-�-f__ ____ Disposal Field: Distance from nearest well.-._~-�-_----_Distance from foundation----/_ --------Distance to nearest lot fine____.... [s� Number of lines______-----.-. <____ _.___-___Length of each line. f - � ---��---------Width of trench---- --------------------------- Type of filter mate rial/,6�Q�Depth of filter matenal__�� _________Total len --- 27 �_______________ -- Seepage Pit: Distance to nearest well------- ----------Distance m foundation---- ®.!.___.Distance to nearest lot line___c4~_-�.. �+• p� Number of pits----- ..-----------Lining material_ p�A�'___Size: Diameter-.% ---____Depth___ Cesspool: Distance from nearest well-----------------Distance from foundation.-.-----------------Lining material-----.-------------.___________-_____. rC'7 ❑ Size: Diameter------•-•-----------------------------Depth----------------------------------------------------Liquid Capacity------------------------....gals, .S? Privy: Distance from nearest well----------------r_-.______________. g______._______.___-_____ __________-_Distance from nearest building __________________ ❑ Distance to nearest lot line.-----:---------------------------------------------- ^ ------------------------•--------------------- Remodeling and/or repairing (doscribe):------ ------ ----------------- -------------------------------------------------- -----------------------------•-----•------•----------------•---•-------------------------------------------------•------•----------------------------------------------------•------------•-------------•------------------------ -----------------------------------------------------------------------••-•---------------------------------------••--------•----------------------------•---------- ---- --------•-••---...--------------------- 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 regulations of the San Joaquin Local Health District. (Signed) /j�Ll/�------ --------•------- � ---��-•-- - ---------------------------- - -------------- Contractor) BY --•------•----------------------------------------------------------- ---------------•---- ...........----------------- (Plot plan, showing size of lot, location of system,,i elation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY �s APPLICATION .ACCEPTED BY_-_-- :-s--L�-'--- yS ---------------•.----------- DATE----1_--"--"Z-b-- - ----------•---- REVIEWED 'BY:"t*---------------- --- --------------------------------------------------------- •--------------------------------------- DATE---------_------------------- - -- -------------------------- BUILDINGPERMIT ISSUED--------------------------------------------------------------------------._..-..-------------------- DA•TE--------------------------- -------------------------------- Alterationsand/or recommendations:-------------------------------------------------------------------------------------------------------------------------------- --------_------ ---•------ ---- ----- --- =--- ------------------------------------------------------------ =- - ------------------------------------------------------------ -------------------------- ---------------------- ------ - ---------------- ---------- -----------------------------------•---- ------------------------------ ------------------------------------------------------------ FINAL INSPECTION BY:.._�_, _- .' - Date------ -4------(�--------------------- --------------••-•----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California lodir California Manteca,California Tracy,California E9.9 REVI6EC F a-59 ,P.cc.ZM 6.60 .V-wn .w-F.- •� tiurf' .-