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FOP OFFICE U�E: -,3--Q ----'� - - ----� - - Permit No. ----- .�°Z---��I-- .f7fCc - � _ APPLICATION FOR SANITATION PERMIT ------------ --------------------- pate Issued .----------------------- r (Complete in Duplicate) �` .....----- I ------ This Permit Expires 1 Year From 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 AND LOCATION.... - �5 ------ --. - - - ... --------------•--•-----------------------•---- ----------------- --------------------•--------- �} Owner's Name------------- � Phone-------------••------------_----- Address--------------� ..__. � -------•------------------------•--- Contractor's Name-------• Phone Installation will serve: Residence gk�'_Aparfinent House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _Z_ Number of bedrooms -. Number of baths,l _ Lot size1k__1 ----_---------_----------------------- Water Supply: Public system 0 Community system ❑ "F—'rivate ❑ Depth to Water Tableft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Lbam ❑ Clay ❑ Adobe 21 ardpan ❑ Previous Application Made: (If yes,date---------------------) No grPew Construction: Yes 2-lTo ❑ FHA/VA: Yes Er—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__ZP...._.____.Material---- _e- No. of compartments-------- 2� -_.____ Size,_--_---- --------Liquid depth__--' -----------Caity-�- Disposal Field: Distance from nearest well..................Distance from found&tion___Zjp________.Distance to nearest lot line-4 ....... Number of lines----___ _ 1 Len th of each line_______ __ �—`____.Width of trench.__ _________________ f3' , g , Type of filter Depth of filter materiaL__l! ___:____:_Total length-----Ae�. -----__________________ Seepacp_pit: Distance to.,nearest well-----.-�'__-_Distance from foundation____•_e/Z?._....Dis?farce to .nearest lot line---%�._______-- Number of ________LLining mat � .--Size: Diameter__. Depth--- ----------------- Cesspool: Distance from nearest well---------_-------Distance from foundation------------------- Lining material-----------...._____:_•_--__-_.._____ ElSize: Diameter ----------Depth----------------- ---------------------------------Liquid Capacity.-,----------- -------gals. Privy: Distance from nearest well__________________________________________f_._Distance from nearest building------------------------- ❑ Distance to nearest lot line.------------------------------------------------•----------- ----•----------------•--• ------=----------------------- Remodeling and/or repairing (describe)--------------- " .... ------•-----------•---• ---------- -----------------------------------------•------•-------------------------------- - - --------------------•-----------------------------------------------------------------------------I——----------------------•---------------------------------- I 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)-------- -------------------- ------------ -------- --- -------------------------I-----------------------------------(Qwmep-sad�or Contractor) By:------------------_-----------_----------------------------- --------�/f�4c ----------•------•---------------(Title)---r��/Zf�l--r--------•----- --------------- - (Plot plan, showing size of lot, location of syst to relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY ` APPLICATION ACCEPTED BY '`�--- ---------------------------- ---------------------------- REVIEWEDBY------------------------------------------------------- -----------------------------------------------------------------._.. DATE------------•---------•--------•-•--•-------------••-------- BUILDING PERMIT ISSUED--------------------------------------------------------------—------------- DATE. ------- Alterationsand/or recommendations----------------------------------------- ------ -------•------------•--------------------------•-• ----------•-••---------------•----------------------• ------ --------- �---� -- .- - - -- -------------------- ---------------------------------------- � - r ::::::-- �J FINAL INSPECTION BY:... <.`-- ---- t v� Date---------�-- 1 ------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 4Th Street Stocktonr California Lodir California Manteca,California Tracy,California 1 E9-9 REV16£D 9-59 F.P.CO.2M 6.60