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FOR OFFICE USE: _ ^y- ---------- -------------- APPLICATION FOR SANITATION PERMIT Permit 'No. L_ ........... ------ ------------------------------- -------------- -- (Complete in Duplicate) -- -- -----=---------------------- -- -------------- --- I This Permit Ex fres 1 Year From Date Issued Date issued Application is hereby made to th`e San Joaquin Local Health District f r a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 9. Z7 - -- --------------- JOB ADDRESS AND A N__._-- � / ------- --------&,CeQ Owner's Name---------- ---------- Address --------- Address__. -- --- -- - --�- G--- -- --- - - ------- Phone _7Z11f -7-_-- --- i ----- ,Contractor's Name- ----------�- -5�----- __ Phon � _--- l -------------- Installation will serve: Residence 9 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms _______ Number of baths -- ----- Lot size Water Supply: Public system ❑ Community system ❑ PrivatejK Depth to Water Table 2S ft. j Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeK Hardpan ❑ Previous Application Made: (If yes,date-.------------------) No)CL 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-S�-_____Distance from foundation__/V______-.Material__ --- Size- -- __X �- -- -` 6------ p -_ = Liquid deth 'S r. No, of compartments_-__�____-- ------ .� ..........Capacity--- Disposal a acit Disposal Field: Distance from nearest weft_ Q_� Distance from foundaticn__20---------- Distance to nearest lot Number of linves__A� --- -e--- _ Length of each line_________� �--- -�i-----Width of trench.Type of filter material-_ f�f_r --Depth of-filter material _______I ��_ �--------- -------- ------- ---- --------- ----------_----------- Seepage �\ � Pit: Distance to nearest wO------- from foundation-------.-----------Distance to nearest lot line----------------- El Number of pits----------------------- ----------------- - Lining material----------------------.Size: Diameter-----------------------Depth-------------------------------- ' Cesspool: Distance from nearest well-------------- from foundation____----------------Lining material------------------------------------- El_ _-_-____-_.___---- -_-_ .- ❑._. -Size:_Diameter=--- - --------- ------------------Dept h-- ---- --------Liquid Capacity- ------------------- gals. � -� Privy: Distance from nearest well_________ _______"_--------------------------Distance from nearest building ❑ Distance to nearest lot line___- Remodeling and/or repairing (describe):__ f �(,L1------------ -- -- ---- ---•--------------- ------- -------- ----------------------------------------- C --------------------- -------,._. ------- - ----------------------------- --------------- --------- --------------------------- -----------------------------------------------------•----------------------------------------------------------------------------------------------------- --- ------------...... I hereby certify that I e prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, d r s and regulati s of the San Joaquin Local Health District. (Signed)-------------------------- ---- (Owner and/or Contractor) ----- ------ ----------- BY=------- ----- `------- ------- - ------(Title)------ '.� of plan, showing size of of, location of system in relation to wells, buildings, etc., can be place on reverse side). FOR DEPARTMENT USE ONLY---------------------- APPLICATION ACCEPTED BY------ -------------------- -------------------- --- ---rte -------------- DATE-- REVIEWEDBY- ------:--------------- ------------- ---- ------------------ - ------ DATE BUILDING PERMIT ISSUED--I--------- - - ATE- - ---- --------- - --------- ------------ Alterations and/or recom endafi s:_-- ... _-_ + -- ----------------------------- =_ --• -------------------------- ------------------ ----- --- ----------------------- ---------- -------------- �� 6" FINAL INSPECTION BY: --- ..------ d� Date---- �-- �'1 /. ---------- SAN SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 F.lfazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street i Stockton,California Lodi,California Manteca,California Tracy,California A �