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FOR OFFICE USE- ------------------------------------------------------ l APPLICATION FOR SANITATION PERMIT Permit No. --------------------------------- _ -©•__.QI_ --------- ----------------------------------------------- (Complete in Duplicate) ----- This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District fol a permit to construct and install the work herein described. This application is made in compliance with ountOr ano. JOB ADDRESS AND LOCATION,/V_,x?- _ -[--�t� , -- -------------------------------- ------------... Owner's Name -+ �r� A/ -_ = Phone Address _ G. G �----f i� r• � t v -------------------- Phone------------- Contractors Name��- ?l�fn 2' �r �/ {M C :--`'---- «= Installation will serve: Residence Apartment House ❑J Commerc;al ❑ Trailerourt ❑ Motel ❑ Other ❑ Number of living units: --_f---- Number of bedrooms .3... Number of baths -sZ--. Lot size . '�_. __ �1 -� - - --------------•- Water Supply: Public system ❑ Community system ❑ Private A Depth to Water Table/M ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay Adobe ❑ Hardpan F] Previous Application Made: (If yes,date--------------------) No I L New Construction: YeP No ElFHANA. Yes ElNON � TYPE OF INSTALLATION ANIS SPECIFICATIONS: !! (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest wnell_ � istanc from foenda`tion------J_d--------Material__'_ .. A No. of compartments-A-------------------- _�U___,>&quid depth___.____ _� __Capacity45cl - Size___ _ Disposal Field: Distance from nearest well..--9-df710istance from foun tion___! !_- Distance to nearest lot line_ --- Number of lines_____ _, .� _.._____ ,_Length of each Iin� ,G" __� Cvdth of trench___.____ f_f �T � �" Type of filter material-21i Depth of filter material_______ _ Total length--------2—L- ------------------.- 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------------------------------------- Size: ..___._----._.._.__----- - Size: [Diameter------------------------ Depth--------------------------- ----------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---------------------------------._....... ❑ Distance to nearest lot line------------------------------------------------------------------------------------------------------------------------•-- ----------------- Remodelingand/or repairing (describe):--------- -----------------------------------------------------------------------------------------------------•-•-••----------------------------------- ------------------------------------------------------------------•------------------------------------------------------------------------ -------------------------------------------------------------------------- ------ ------------------------------------------------------------------------------•-------------•--•---------------------------------------------•-•--•-•---------------••------------------------------------------------------ I --------------•--------------------------------------------------•--• ---------------•-------•-------------------------------------------------• --------------------------------------------------------------------------- I ------------------------------------- ------- ---- 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 a d #gulations of the San Joaquin Local Health District. (Signed)-- ----�� ----------------------------------------------------•------------(Owner and/or Contractorl By:—:------- ---- ------ ITitle)= (Piot plan, showing si a of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------------- --- ------------------------------------------------------------ DATE---------- -------•-------- ---- ------ ---------------- REVIEWEDBY------------------------------------------------- ------------------------------------------- �. •'�� _ DATE--.-5-------/1•---. ' .- ------- ------------ BUILDING PERMIT ISSUED---------------------------- DATE--------------------------------------------------- Alterationsand/or recommendations:------------------------------------------------ ---------•---------------------------------------------------------------------------------------------------- ---------------------------•----------- ------------------- ----------------------------------------------------•------------------------------------------------------------------------------------------------------------- ---------- -----•----•-------------------------- -----------------•-------------------------------------- ------------------------------------------------------------------------------------------------------------------------------ --------------------------------------- ----------- - ----------- - --------------------------•--••------------- ----------------- --------------------------------------------------------•----------------- FINAL INSPECTION BY------------ ----` ----- _ _ 1_-C� ._..--- bate------------------- y' � �� -`� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California r.s 9 Revsrro 8.59 3m 3-'63 r.P.cn.