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FOR OFFICE USE: l z , F 7.7 = -------------- --=-- --------------------------- - Permit No. ------------- •---- -- = APPLICATION FOR SANITATION PERMIT ---------------- (Complete in Duplicate) ---------:--------------------- ------------------------------Date Issued----��•-:/�- --�/ _---- _--.-__ -'This Permit Expires 1 Year From Date Issued ----------------------------- i 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 a. 54 'x'775" S041f JOB ADDRESS AN 0CAT10N. = -• / 'i4�? ----- Owners Name- ------- 0 ---•• �f- ------�----`=-------------------------- Phone 0 z A0K --/A/------ Address..G-. ��1.T ems:- .�-.. ..................... et� '1f �.� �r�' �---------------•----. Phone 7_Contractor's Name- - ----------- Installation will serve: Residenceuse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ / i Number of living units:._)--- Number of bedrooms .�- Number of baths .---- Lot size ••---•-------•-•- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Tableft. F Character of soil to a depth of 3 feet: :Sand 0 Gravel f-1Sandy Loam [I Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan C-] tr Previous. Application Made: {If yes,date..---------- 1 No New Construction: Yes No ❑ FHA/VA: Yes E] No [I �a TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank'or cesspool permitted if public sewer is available within 200 feet.) Sep is Tank: Distance from nearest well_:-A/F-z Distance. from foundation---/&. -_---- Material------.. � 1�-r------•------••- Size ---- Capacity No. of compartments-.---�----.----- ?�_3 --}--. Liquid depth.--- --_--------- T� Disp sal Field: Distance from nearest ell. �1e'__ Distance from foundation= Q:-��--...--Distance to nearest lot line�� -- -.-.__ lv Number of lines__ -.--f -_--.--- - Length of each line' -S`-. =- -Width of trench ---..a------------• <k Type of filter material__C_,&'. .Depth of filter material-- _-_--------- Total length ......... hr -------_------------ Seepage Pit: Distance to nearest well ---------------------Distance from foundation --------------------Distance to nearest lot line.____--.._-----._ , ❑ Number of pits------ ----------- Lining material ---- -------------- Size: Diame#er Depth Cesspool: Distance from nearest well ---------------- Distance from foundation --------°-----_.---.Lining material_--_- .---.----------_--------.----. ❑ --.Depth--------- ' •------ ----- ----------Liquid Capacity. gals. .. Size: Diameter---`-------- ------------- ------- Privy: Distance from nearest well --_-------------'--------'-'----•----•-------•----Distance from nearest b0ding ------------------------------------------ _ O� x . w ------- Distance to nearest lot line----------------`----------- --------------- ------•-------------•----------------- Remodeling and/or repairing (describe- ------------------------------------ ---------•-----•-•-------- I ---•-- ---------••------•----------------•--------------------------- \4 : ------------------ ----------------------------- a•-•--------••---- ----- ----------=--------------------------------------------------.----------•--------• •-- --------- =- --------= -------- ------ - ------------ ---- I hereby certify that I have prepare is -application and that the work will be done in accordance with San Joaquin County ordinances, State law ' nd r s an egula ions of the San Joaquin Local alth District. --- -- -- -- ---- Vii`-..-.-- (Owner and/or Contractor (Signed)-----•-----• -------"-- --------� - ---- --- ---- -- - ------ -- - � BY: ------•--- -------------------- ----(Title)--- (Plot plan, showing size of lot, location of sys em in relation to wells, buil Ings, etc., can be placed on reverse side}. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----------------------------------------------------------- !� - -DATE----- �� .. '--•-----.. DATE--------- ----------------------------------- REVIEWEDBY ------------------------------------------ -----------•- - BUILDING PERMIT. ISSUED -------_------------- ------------–------------ -- --- Alterations and/or recommendations:_--_.-.--------------- ---------------------•----------------------..-.. - -------------------------------------------•------ ------------------------------------------------------ ---------: ---------------------------------------------------------------------- FINAL INSPECTION BY: ---- ;P — -- ------ Date---- -SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 3oo West Oak Street 124 Sycamore Street 205 West 9th Street Stockton, California Lodi, Californla Manteca, California Tracy, California r.9.9 REVle Eo 9-s9 R.P.C13, 1M 6.613