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FOR OFFICE USE: ---------------------------------------------- ---------- -------- ------------------------------------------------ APPLICATION FOR SANITATION PERMIT Permit No. --------------------------------------------------- (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 construe# and install the work herein described. This application is made in compliance with County Ordinance�Q.�9. S g � JOS ADDRESS A OCATION_1-'-'1" "( �,Q ti`' IXA----- •---------/------------- Owner's Name-------- - -- •------• - -- - ----�------------------ - - -- - - - - ----��-'7�' ------------•- • P Address----------------- 14 . ---- - --- ------- - Contractor's Name------ ----- -- ------ ------ ------- Phone. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __l___ Number of bedrooms _3--- Number baths ""Lot size --- ___________________ _____ --------------- Water Supply: Public system El Community system ❑ Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam El Clay Loam El 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 ank: Distance from nearest well _c t d_ .__Distance from €oundation_..._/4__._..__. Material------ --------- ----- ----------- /w No. of compartments-------`--------------Size_ 111 __1__1x_X1'_tiquid depth_ :i V..._..________Capacity___�3 a . i i .. / s Dispo Field: Distance from nearest well- Distance from foundation----/.d,___-.___-Distance to nearest lot lines-_:_________. Number of lines.------- Length of each line______ ,B f Wi 2------- -�j 9 - F - d#h of trench ---.----------- --------- Type of filter material-------- ,Depth of filter material____ Total length_-fi d_____________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__._______.__..__ ❑ Number of pits___-------_-----------Lining materia ----------------------- Diameter-----------------------Depth-----.___.------------- ________ Cesspool: Distance from nearest well--------------___Distance from foundation--------------------Lining material___------------------------f______.__. ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity- ------------------------ gals. Privy: Distance from nearest well--------------------------.----------------------Distance from nearest building------------------------------- ____._._. ❑ Distance to nearest lot line----------------------- -------- ' ---,--- 1 Remodeling and/or repairing (describe):------------------------- --------------------------------------------------------------------------------------------------- -- - ------------------- --------------:------------------------------------------------------------------------------------------------------------------------------------------------ -------- ------------------:-•----------------------------------------------------------•---------------------------------------------------------------------------------- -------- --------------------------------------------------- --------------------------------------------------- -------------- j I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances,'State I and rules and regulations of the San Joaquin Local Health District. (Signed)_______________ ________________4_____.____ h_____q� in .. —"(®wrrer.and/ar Contractor) By:---------- - --------- - ------ t ---------- - --------------------------------(Title)------------------ ------------- - --- (Plot plan, showing size of lot, location of syrelati to wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- " - /------------ ---------------------------------------- DATE---`r -------- - - ---------------- REVIEWEDBY--------------------------------- -------------------------------------- DATE--------r---•----------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE--------------------------------------------- --------------- Alterations -- ----- - Alterations and/or recommendations:---------- -------- ------------- --------------------------------------------------------------------------- ------- ------------------------------------------------------------- ----- - - - ------- ------------------------------------------------------•--------------------------------------------------- ----------------------------- ------------ ------------ ------ -- ---------------------------- ----------------------------------------------------------- - - ------------------- --- ----------------------------------------- FINAL INSPECTION BY:_.41_+_�._'4!s'� ----------------- Date-- -. -`-- ---------_ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hasellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California r '3