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Akv�ICATION FOR SANITATION PERF,,,, Permit No. ., _,!%1 .��'.J� ------- ----------------.------------------- ------------ (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 the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS A LOCATION...,*/-10 ... .'` ...�?-r __ ; ._��_�I`__. ... _ �P . >—'-- Owner's Name.--- 7t'1�,y �'d��a.�.��..-.---••-----•-•-••-----•---------------------------------- ---- ------------------------------------ Phone.......------. •-------•------•----- Addressf 1' -'--------------------------••-------••---------------------.--------------.------------------------------------ Contractor's ----------------------------------------------------- ............................................................... Phone................................... Installation will serve: Residence [I 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 ❑ Private ❑ Depth to Water Table -------- ft. 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 SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well.................Distance from foundation-..---.---.-- _..---Material................................................. p No. of compartments------------- ---- -----Size----_--------•--- ............Liquid depth----------- ------------ Capacity----- ................. Disposal Field: Distance from nearest well.................Distance from foundation....................Distance to nearest lot line................. ❑ Number of lines-----------------------------------Length of each line..............................Width of trench..... ........ ,N' Type of filter material_----------------------Depth of filter material...-------------------.Total length.--.----.-._----__-.-_-----------..-_----- � Seepage Pit: Distance to nearest well.�%`G'�.:f.......Distance from foundation.-�q............Distance to nearest lot line_,� Number of pits.... ----------------Lining material/- 1------------.Size- Diameter----13 ------- Depth.,r�'..................... v. Cesspool: Distance from nearest well-----------------Distance from foundation....................Lining material..................................... p Size: Diameter-------- ------------ -------------.Depth----- ....... ------------------- .. ------------Liquid Capacity. --- ----•-----------...gals. Privy: Distance from nearest well------------------------ ------------------------Distance from nearest building---------------------------------......... , ❑ Distance to nearest lot line------- -------------------------------------- -•------•------------------------••---------------------------------1____1------------------- Remodeling and/or repairing (describe):-- ----- - v . _------------- ------------- --------- ------------ ----------------•-------------•-------------------------------•---------------------------------------------------------------•------------------ - -- ------ - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinance , State laws and rules and-re ulations of the San Joaquin Local Health District. (Signe - - - -_----------- (Owner and/L- Contractor)d I i - By:------------------ --------=-------------------- ---------------------------------------------------------------------------------(Title)-------- ---------- -- (Plot(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). C FOR DEPARTMENT USE ONLY A APPLICATION ACCEPTED BY_. ra+ ........................ ........................................ REVIEWEDBY----- - --------------------------------------------------------------------------------------------------------------------- DATE_......................................................... BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE---------------------------------------------- ------------- Alterations and/or recommendations-------------•----- -----------• ----•----- •----------------------.-_---._-----------------------.-_-_--------------------•----••-•---------------------------- --•-•-------•-------------•------------- ---•----------------------------------- ................ -----•--------------•--------•--------------- - -----------------------------------------------------•-------- ... -------------------•---------•--------------------------------•----•----- •-------------------------------------- ------------------------•---- ------- . ••-•-•-----•-----•--••------------ ----------- ------------- --------- ---------------•-- --•-------------------•------------ .............................................. ----- . -- -------------------------------. ---- .. - --- ----------•-------------. --•- ... ............................... ------. -----•......... -••-•------------•------- -..... -- ...... . ---- ..._.------................. / -! Gt.� FINAL INSPECTION BY:.. ................................. Date.... ....��- ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street h 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CO. if