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FOR OFFICE USE: - ----------------- --------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ...... .... - ----------------------------------------- ------------- (Complete in Duplica+e) v ------------------=----------------------------' Date Issued ___:_ This Permit Expires i Year From Date Issued2 3 e)2-o—S3 Application is hereby made to the Sari 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"OCATION_C�... 1_ - ------------------- Sets+ -------------•---•Owner's Name --- __ ___ __i s= -------- - Phone Address........ t---Zo-- ----------- ------- Contractor's Name------ -------• --------------------------- �/"► ° - ------------------- Phone__.'.._....:._...- Installation will serve: Residence Apartment House ❑ Commercia Trailer ourt ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths ___:____ Lot size ----- 15 .....:.......` ___.__ ---------_--------- Water"--Supply: ____._...._______._WaterSupply: Public system ❑ C 6mmuriity system ❑ ' Frivate-W Depth to Water Table t. Character of soil to a depth of 3 feet: ,Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe,g Hardpan ❑ Previous Application Made: (If yes,date_____ -------- -----) No New Construction: Yes No ❑ FHA/VA: Yes-[I Noe t , TYPE OF INSTALLATION AND SPECIFICATIONS: _ (No_. septic tank or cesspool permitted ifTpublic sewer i, available within 200 feet.) Septic Tank: Distance from nearest well `_Distant fro fou�fion_-_-J Y__._.Mat ria-__- ___- _ C� ,,�` No. of compartments_____--____-- --.- .-�±------Liquid depth----'--- --____-- F'� y� 512e_____ _.__ 1 � /l 55 Disposal Field: Distance from nearest well../"_-*__Distance from foundation_A.0---_.___.Distance to nearest lot �f Number of lines---- Length of each line________�A-_______.Width of trench.___. ,-. ._`.'_______________ Type of filter material._ _ .. Depth of filter material__ __ ____________Total length____-Q__---------.------____-____- 5. Seepage Pit: Distance to nearest well-------------__.---__Distance from foundation___.................Distance to nearest lot-line-_`____________ ❑ Number of pits---------------------Lining material---_------.__._- ----.Size: Diameter----•'--.---- -'----- -Depth----- ---------------•--•---•_-.- Cesspool: Distance from -nearest well-________________Distance.from foundation--------------.__-.Lining material_____.._-__-____________.____________ N❑ Size:.Diameter.--•--------------------------- ----Depth-------- ----- F-------:---- --------------- Liquid Capacity-----------------------• gals. _ +�e��.e-`. �R-�l. �.YYF�. art'-S._�w,.� -. .._„I Distance from nearest well ___________ _____ _________ _________Distance from nearest building-_-__. _____.-------------_-------------- Privy-7 ❑.. . Distance to nearest lot line--=------ ------------------------ ---------------------••--------•-------------------------------------------------------------------•-------- r n r ` Rema ling<a d/or airing'd scribe):---- ------- ----...a --------------=--------- ---------------------------------------------------------------------- ------------------------------------------------------------------------------------ ------------•----------------•----------•----------------------- I'here6y certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, a rules and'regu tib s of the San Joaquin Local Health District. (Signed) �------- ---�'"-�'-"-'- °--------------------------- ----------------- (Owner and/or Contractor) �By= -=;; —F��—;;:_--:---- ------------•--- -----------------------------------------------------------------(Title)-------------------------------------------- --------------- (Plot plan, showing size of lot, Iota+ion of sys+em in rela+ion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY---------1--=------------------------------------------------•-------------•-------------------- DATE--------------------=-------------------------------------- REVIEWED_ BY-------------------------- ---------------=------------------ ------ ------ ----- DATE_------ ::: .� BUILDING PERMIT ISSUED---------------------------------------- -------------------- DATE.---------------•---�-�-_. ��.. Alterations and/or recommendations:------ -------------------- ------------------------------------------•-••------------------------•-•-------------•----•--•------•----------- .. -------------------------------- -------------------------------------- ---------•----- -----------••---------•----•--•-----------..._....----------....-------------------•----------------------------•------. r FINAL INSPECTION BY:-------- -------------- ---- -- ------ --- �� Date---------- ..----- ----------•----------------••--- '-•-•-•-•---• SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street C205 West 9th streetStockton,Ca4forriia Lodl,California Manteea,California rpey,California £9-9 FEVI6E0 6.69 F.P.CO.SM 6.60