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FOR OFFICE USE: ----- -- -------- APPLICATION FOR SANITATION PERMIT Permit No. . �1��.. - -- --- --- ----------- -- (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 cons rust and install the work herein described. This application is made in compliance with County Ordinann e No. 49., u j JOB ADDRESS A D LOCATIONIIst- ` �'-d►ri-,t4_.9... Owner's Name •-----------•------- ------ Phone--------------------_------------- . __ ,� `�? ,. - ------------------------------------------------------- r Address_______ J Contractor's Name---- - -------- r ..•. -- --- ___`--- / 1 ---------------------- Phone------------------------•- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living __-_--- Number of bedrooms _ units: I __._ Num7Depth f baths __�__ . Lot size ___ Water Supply. Public system Communit s stem Private to Water Table ___----_ ft.PPy Y ❑ Y Y ❑ 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 SPECIF[CATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) a Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material-------------------------------.--------- ___-__ ❑ No. of compartments--- -- -----------`__Size- -------------------Liquid epth--------------- --------Capacity-------------- ------ "h Dispas field. Distance from nearest well--_-4�^ 7`Distance from foundation-__._�1t7_.........Distance to nearest lot line_x_�y--_-__- ` Number of lines-- --- ----------------------Length of each line-----------5 '---- --._---Width of trench.---- --- Type of filter material__--_---�'-_kt+-_---_Depth of filter material------_41---------Total length-_---�7--------------------------- Distance to nearest well____- __-(__Distance from foundation-----/F2_�__-_.Distance to nearest lot line-- -------._ ❑ Number of pits--------/----------Lining material------ t- '----..Size: __ .X-1-----Depth------/5.`7---------------- Cesspool: Distance from. nearest well-----------------Distance from foundation....................Lining material--------------------------_-__-_-_ [❑ Size: Diameter--- ----------------- --------------,Depth----------------------------------------------------Liquid Capacity----------------------------gals. i Privy: Distance from nearest well----------------!------------------------------ -Distance from nearest building_____-_--_._-________-_____.________._. [] Distance to nearest lot line--------------------------------------------- ------------------------- ---------------------------------------------------------------------- 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, Stat a 7, and rules and regulations of the San Joaquin Local Health District. -___ t-_ nd or Contractor (Signed) - ) BY:----- (Title)----------------------- (Plot plan, showing size of lot, location of system in elation to wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE '' '- '- --------------------------- REVIEWEDBY--------------------------------------------- ------------------- ----------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE--------------------------------------------- ----------- Alterations and/or recommendations------------------.----------------------------------------- -------------------------------------------- ----------------------------------------------------------------------------------------- ---------------------------------------------------- ------ ----------- -------------- 1 FINAL INSPECTION BY:. {.... - = Date. 'S'— ?— JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Maselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca, California Tracy,California a F.P.C C.