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FOR OFFICE USE: -----------------------------=------------- ------- ____________________________.___.____-____-____ APPLICATION FOR SANITATION PERMIT Permit No. !'.-�vl3s` ----------------------- ---------------- e) {Complete Irt Duplicate) Date Issued Date Issued ----------- --- --------- - - --------.--------- This Permit Expires 1.Year From _ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described.. Th' application is made in compliance with County Ordinance No. 549. - JOB ADDRESS A p LOCATION. __ ----"--_�oZ - •- ••- -- ------------- ------------------- Owner s Name--- _. ;_----- -------- - Phone _,.. n ••�� T Address2.x�-9-4-------- -• -,�! r_�1 _. Contractor's Name `� - ------------------------- ' Phone_` - Installation will serve: Residence ❑ Apartment HouseVINumber ommercial [-] Trailer Court E] .Motet ❑ Other E]Number of living units: _- __- Number of bedrooms of baths _:_fY___ Lot size _, Q_,Si- � _ - "---_____ Water Supply: Public system ,Community system ❑ Private ❑ Depth to Water Table _40 ft. Character of soil to a depth of 3 feet: }andx Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [❑ Adobe [❑ Hardpan ❑ 'Previous Application Made: (If yes,date----.---------------) No [Q New Construction: Yes No ❑ FHA/VA: Yes ❑ No ❑ 'TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if ublic sewer is available.within:200 feet.) Septic Tank: Distance from nearest well_Distance from foundation_ _ Material ------ ------- No. of compartments-._ 42.._.,-----_-�--___Size_�.f�,e X_ _ /r�`Liquid depth-_._."y_�.....__..._Capacity_,o�C344_ 'Disposal Field: Distance from neares well/t Distance from foundation—e/- `p. Qistance to nearest lot line- Number of lines_____ ___ ___ Length of each lineM-V-.$7= 6 Width of trench----_,�____ __ Type of.fil#er mat 14_____ .Depth of filter material____-I"- "-----Total length___-C!-_____ _- �� _ :Seepage Pit: Distance to nearest well ---- from foundation_ -_-'._...___.Distance to nearest lot line----------------- ❑ Number of pits----------------------Lining material_=_"` " _'"� .Size: Diameter---------------------- Depth >---------------------------• Cesspool: Distance from nearest well-----------------Distance from foundation'-------------.... materibl__..___.._.__.___________-____ -----. ❑ Size: Diameter--------------------------------------Depth-------- -------------------------I---------- ;----Liquid Capacity---------------------•----•-gals. Privy: Distance from nearest well------------------------------------------------- from nearest building----------"-----_______.______...___--- ❑ Distance to nearest lot line__________________ t ; ----------• ------------------------------------------------------------------ -- Remodeling -emo a Ing and/or repairing (describe): ------------------------------------ -- -- --- -- -- -- -- ----------- -------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------- --------------------- ------------------------------------ -----------------------------------------------------------------•----------------•-•---------------------•-----------------------------------• --------------------------------- ------------------------------------ ------------------------------------------------------------------•-----------—------------------------•---------------------------------------•----•-- --------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ,ordinances, laws, and rules and regulafio of the San�Joaquin Local Health District. d ----------- .��/ r (Signe �---- ------------ -"r -- =------ --------- --- ----- - --- caner and/or Contractor) � ^i -------------+--- By: (Title) t Y• -- -------------- (Plot plan, showing size of lot, location of system in relafi to wells, buildings,`etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY--------- s.. _ C :------ ---------------- ---------------------------------------- DATE------ d ' REVIEWEDBY---------------•---------------------------- ------------------- - ------ ------------------------------------------- DATE-------------: ---•-------------------------------------- !BUILDING PERMIT ISSUED `------------ -------- - ----------- --------- DATE--------- ---------------------------- Alterations and/or recommendations--------------------------------------- `r -----------------------------------------------------------------------------------------------------------------------------------------------------•-----------------------------------------------------------•----- ---------- ------ ----------------------------------- ------------------------------------- --------- ---- ---- - ------ -------- ---- --- - -- - - FINAL INSPECTrOti-�BY:--- - - -- --- -- ---- .- Date----------- % - --�� -------------------------- o . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E:Haftelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street -e Stockton,California Lodi,California Manteca,California a , kTracy,California , IFS 9 REVISED 8-59 3M 3-'63 F.P.DD.