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FOR,OCE-USE`— s --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. I --------------------------------------------------------- (Complete in Duplicate) ------------------------------------................ This Permit Expires I 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. 1 JOBADDRESS � Q_ z -------- Owner's Nam ----------= t Phone -------------- --------- --•------•------- ------------ Contractor's Name.---- ----------------------------•---------------------------------------------------------------------------• ------- ---- Phone...N-Ox-.Q ................. Installation will serve: Residence g Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _(._-__ Number of bedrooms -3-..- Number of baths -_1_- Lot size ___-] ._ _._ ,- Water Supply: Public system ❑ Community system ❑ Private X Depth to Water Table 1s.- ft. f r Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam ElClay Loam El �{-Clay N Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date----------- ) No New Construction: Yes g No ❑ FHA/VA: Yes ❑ No STYPE OF INSTALLATION AND SPECIFICATIONS:,_- (No Septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest woll_.�Q-------Distance from'foundation-----IP--------- Material----cm�--- ______________________ No. of n com artrents_._______ p ,� -- 5ize_4.t.XA0---------------Liquid depth_-,--12�-'-------------Capacity....3jqn-n----- I ! I f Disposal Field: Distance from nearest well__ ________Distance from foundation___1_Q.-----------Distance to nearest lot line__.._r-�_______ i ' french--- A.t ® Number of lines.-_______l�.________---_ --_- Length of each Iine�0b00--i(30 ..Width of jil --a----.______..-___________ O Type of filter material_ �.. __Depth of filter material_____1R------------ Total length_._.__` __--_____. Qi Seepage Pit: Distance to nearest well--------------F-------Distance from foundation--------------------Distance to nearest lot line_________________ ❑ Number of pits.1--------------------Lining material------.--------- -----Size: Diameter------------------ ----Depth----------------------------_---- Cesspool: Distance from nearest well---------- Distance from foundation:...__.----------..Lining :naterial-_.-.____...________.________-__._._ t ❑ Size: Diameter-_,_-------------- -- ------- Depth ------- ------------------Liquid Capacity- --- ------ --------------gals. Privy: Distance from nearest well # ___ Distance from nearest building----------------------------------- Distance -__._..__.__ _ _ ____________Distance to nearest lot line - - -- - - RemodelirQ and/or re airing (describe)- - G� -e-ma c_ _ __________________ t ----- ------P-�rJ----�---------Viz'--------- �-- .- - - ------ �-�� - - - - - - - ----------- ----------------•----------------------------------------------------------------------------- ------------------------- ------------------------------------------------------------ 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 5an;Joaquin Local Health District. k ' r - (Signed)----Am-e.,4�_ •' 41 . --- - (Owner and/or Contractor) . � ,,.,�,..�„ ,.-:•..� - .<.. - tea..-..,.�- .�...r RY:------------------------------- --------- - ------------------------ ---- - - ----- - {Title)------- -- -------- ------ -------- -- - -- -------------- (Plot plan, showing size of lot, location of system in_relafion to wells, buildings, Oct can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- ---- __Q1..... - ------------------------- DATE.-----------x_7.5_'. REVIEWEDBY---------------Lv-/- ---------------------------------------- -------------------------------- --- ---------- DATE---------------------- BUILDING PERMIT ISSUED-------------- ------------------- -------------- ---------- - - RATE iAlterations and/or recommendations:----__- �'"--_`—_-_--- ------------------------------------------------------------------------- -- •---•------- P ----------------------------------------------------------------------------- --------------------- --------------------------------- -------- ------------------------ ------------- --------- --------------------------- ------------ ---- -------------------------------- --------------------- - ------------------------------ FINAL INSPECTION BY:---- Date ----- ---------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT l 1601 E.Hazetion Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.0O.