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FOR OFFICE USE: w r•ti l/ S-- ti Z - APPLICATION FOR SANITATION PERMIT Permit No. --- .._.-.. 1�— -- - ---- ------- --------------- 1°---------- t (Complete in Duplicate} -.___.__ I 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. S49. JOB ADDRESS LOC ION -_ �'--------•--------------------------------------•----------....._...........•--. Owner's Name...... li - Phone. ---- --------- ----- - Address ;. -----••---- ---------------------------------------------•- Contractors Name---------- 14------------------------------------------- Phone----------------------------••---._ Installation will serve: Residence [3 Apartment House ❑ Commercial ❑, Trailer C-ztuwt Fer"Motel ❑ Other El f Number of living units: __-4_ Number of bedrooms .el-- Number of baths _Z _ Lot size --•----------------•---••- Water Supply: Public system E-11-ommunity system ❑ PrivateDepth To Water Table .�ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam 0 Clay Loam [3Clay E] Adobe [Hardpan ❑ Previous Application Made: (If yes,date____________________) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ I TYPE OF INSTALLATION AND SPECIFICATIONS: I, (No septic tank or cesspool permitted if public sewer is available within 200 feet.) .: 1 Septic Tank: # Distance from nearest well________________Distance from foundation____.__-____.....__-Material.___.____._.._._____.__....._._-------_.____.___- t 0/ISfl4 No. of compartments-------------------------Size �-:_._Liquid depth-------------------,-----Capacity---------------------- 0 Disposal Field:,, Distance from nearest well_________________Distance from foundation---------------.....Distance to nearest lot line____-.._-___-_- 1,6j 7f Number of lines--------------------- -------------Length of each liner-•--------------------------Width of trent .----------_--------•----•--------- Type of filter material------------_------------Depth of filter ma4rial----------------------- length____.________...____._....______._..�_-_ Seepage Pit: Distance to nearest we1L_I��----.--Distance fr m fo ndatton_.1r��___....Dis�ce to nearest lot line_.�__________ �. I Number of pits-----/_.________Lining material__ ��;-I Size: Diameter .___..__-_____.Depth_-r ._"• i7 Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__.---___________________:._________- ❑ Size: Diameter--- --------.Depth--------------------- -----•---------------- -------Liquid._.CapacitY---------------------------gals. 1. 4PPrivy: Distance from nearest well-------------------------------------------------Distance from ti6arest building--------------------------------------- ❑ Distance to nearest lot line------ •------•----•---•-•--•------•------------•---------------------•-------------- Remodeling and/or repairing (describe):---------_...- ---��'� -------•-•------------------------------------------------•--------- ��1---------------_-• -- -----._...----------••--------•-------- I ----------------------------- ----------------------•------ --------------------------------------------------------------; I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, 5tata laws, d rules and?re Mations of +Ile San Joaquin Locals Health District. ---------------_---- Contractor (Signed)------------- -- ----------• - ----- - ---------------- l B -�-1- - --- )-- ------------ (Plot plan, showing size of lot, location of Sys In relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED gY `" DATE--- REVIEWEDBY---------------------------- -- ---------:-------------•--------- DATE--------------------------------------------•--...---------- BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- : DATE------------------------------------------------------------ --------- --------- Alterations and/or recommendations:-__ A --------- ' _______ _ _ _ ________ HJOAQUIN --------------------- ------•-- ---------------------------------------- �, FINAL INSPECTION BY:......... ..._4-.. --------• - Date---- �-�-�----��- �--�•- -----�- �- .................... LOCAs. HEAI:TH'DISTRICT 130 South American Strut 300 West Oak Street 124 Sycamore Street .205 West 9Th Street I Stockton,California Lodi,California hlanteea,California Tracy,California 6 E'S 9 REVISE[) a-59 PM 5-60 ATLAS s:ss.��?•r. Ei