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I _ 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 construct and install trhw7o k heref4l,d crbed. This application is mad,� in mph ce with Count inan e No. S49. f f JOB ADDRESS AND LOCATION.- Owner's Name --- . _ Phone. ., --------•----------- - - Address-----� �✓ Lf - = --------------------------------- 61 Contractor's Name / c � f �F '--------------- --- -- .. Phone.----- ----•---------------------- Installation will serve: Residence '-Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .- Number of bedrooms Y_._ Number of baths -/.-_ Lot size Water Supply: Public system ❑ Community system ❑ Private Ra'Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe ❑ Hardpan a-- Previous Application Made: (If yes,date ) No (5/_New Construction: Yes g+--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 w,e�j4_-_7C'------Distance from foundation-_-i _11 ._ Mat�ial- No. of compartments_.,:-- f.�'_ - 1 _' Li uid depth-- .-..._...--.Ca ,cit Disposal Field: Distance from nearest ell.../ _-.._Distance from found __ ation /43_-_.-.--.Distance to nearest lot line- K� Number of lines------- Length of each line---l?55E7-------.--__.Width of trench.------------------ Type rench.---____.-..-Type of filter material __--_Depth of filter material._- ._.-_Total length-,t _ ------------------------ rr Seepage Pit: Distance to nearest well../l `-_--_._Distance fro foun ,tion__ Dist�}'o to nearest I t Number of pits---- ._..__ _.Lining material-- A Diameter_. f 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 buildingC ❑ Distance to nearest lot line.- ------------ 11e. --- ---- ---- - - - - ------------------------------------ Remodeling and/or repairing (describe):--------- � --------------- ------------------------------------------------------------------------------------------------------------ --------------------------------------------- - --------------------- --------------------------------------------------------------------------------------------------------- ----------------------------------------... ------------------------------------------------------------------------------------------------------------------ ------------ --------------------- 1t. 1 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) - --- /_ - � -?If - !"_ -'- - _ -. (SD4P r Contractor) By - ------------------------------------------ (Tale) ._ (Plot plan, showing size of lot, location of system in rely in to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- v:-..c am+ i------------------------ ------- ------------------ DATE-- -- REVIEWEDBY---------------------------------------------- ------------------------------------- ------------------------------------- DATE - .._. BUILDING PERMIT ISSUED----------------•--------------------------------------------—------------------------------------- DATE-- Alterations and/or recommendations:..............._..-__.__.__._._. _. ----------------- --------------------------- ---------------------------------•------------------------ ----------••-•-------------------- ---------------•----------------- - ------ ............... ---------------------------------------------------------------------- ----------- -------------------------------------------•-----------•-- -------•----- -------------- ----------------------------------- - ------------------ ----------------------- ------ ---- ------- •-- --------- .. ... - ---------- - ----------------- ---- ----- - - --- --- -- FINAL INSPECTION BY:.._. � �: __ . ............ . Date.. -✓ . ..- ..._r.. ._..__.. _ - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. Hazelton Ave. 300 West Oak Street 1 24 Sycamore Street 205 West 9th Street Stockton, California Lodi, California Manteca,California Tracy, California F.F',G O_