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FOR OFFICE USE: - --------- ---------------------------------- -- a---------...------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. F ------------------- ------------------------------------- (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 const uct and install the work herein described. This application is made in compliance with County Ordinan. e,No. 549, ry JOB ADDRESS AND LOCATION,_ -- __. � , - Owner's Name__O- ---- ...........` --------------------------------- - Phone----- ------ Address-----•----....�`'Q' ��'�`....1_�� --o-Z04--- ------ Contractor's Name /l-ac'? ----------------------- ----------------------- ------ Phone-------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of livingunits: __------ Number of bedrooms �.•--_ i � . Number of baths ------ Lot size --�-------------------------------------------------------- Wafer --------------- ------------_.------------ -•-----•- Water Supply: Public system ❑ Community system ❑ Private.ff Depth to Wafer Table /_0--- ft, Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam F❑ 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_Z_0__}-----Distance from foundation---w----------.Material ----------------------------- Nalof compartments------�--------- -----Size-A/t-0---_4 ---:---Liquid depth__19-------------------CapacityJ_1?- Disposal Field: Distance from nearest well_4-0-�------Distance from foundation./:�9_'----------Distance to nearest lot €ine__cl''......... i ® Number of lines---------------------------------Length rof eachline-------------------------------Width of trench.,?-_�,_9--------- --- - p Type of filter material%!.,--_ ------Depth of filter material__I_.9---------------Total length__t-Yfr______.._______--_------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation---------------.--- Distance to nearest lot line_-_.____.____. J ❑ Number of pits----------------------Lining material------------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool. - Distance from nearest well----------_------Distance from foundation---------- ---------Lining material____..________.__-_-_---__. ❑ Size: Diameter--------------------------------------Depth------ ---------------------- - --------------------Liquid Capacity-- ------------------------gals. Privy: Distance from nearest well------------------------------------___----------Distance from nearest building-------------------------------------- -- 1 Distance to nearest lot line -------------•------ ---------------------------------------------------- Q , Remodeling and/or repairing (describe}---------------- ------------------------------------------- ----------------------------- -------------1-1-------------------------------------- ---------------------------------------------------------------------- ---------------------- -------------------------------------------------------------- i -------•----------------------------•-•------------------------------•------------------------•----------------------------------- --------------- -------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I ordinances, State laws, and rules and regu tions of the San Joaquin Local Health District. - ' (Signed)---- ---------- 4 ----- ------ ---------------------------•-- ----------------------------------------------(Owner and/or Contractor) l Sy:------------------- ------------------------------------------------------------------ ---------------------------------------------(Title)---------------------- ----- -- -------- ------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). FOR DEPARTMENT USE ONLY ------------------------------------------------- APPLICATION ACCEPTED BY------ ----- DATE--�--t ---- --------------------------------- REVIEWEDBY------------------------------------- -------------------------------------- ----------------------------------------------- DATE BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------- ------------- DATE -- -------- A terations and/or recommendations:------ ------------------------------ ----------------•-------------- --------------------------•--------------------- -------------------------•------- --------------- -------- -------------------------------- --------------------• ------------------------------------------- -------------- ' -----•-•--------- ----------------------------------------------------------------------------------------------- ---------------------------------- ------------------------------ - ------------------ ------------- ----------------------------------- --------------------------------------------- --- ------------------- -- k ------------ — ------ , Dafe---- -:------ - --- --------------•---- FINAL INSPECTION BY:.� � l f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca, California Tracy,California r.P.c O.