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FOR OFFICE USE: --- - -- -- ---- ----- O• APPLICATION FOR SANITATION PERMIT Permit No. ..42- .... ....... ------------------------------------- ------- ------ (Complete-in Duplicate) Date Issued ...__ -- ----------------------- -_. This Permit Expires l Year From 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. JOB ADDRESS AND LOCATION. -- - - " Owner's Name // --------- - Phone------------------------------•---- Address--- -Yl y ----!/V---I------- ------ - ------------ -- }` -------------------------- ---_--------------- -------------------- ----------------------------------------------------- Contractor's Name- - - ---------------------- ----------- ---— -- `----- -------------------- Phone. ^t Installation will serve: Residence [FApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _.I---- Number of bedrooms --.Number of baths .._ ._ Lot size -.._. __. ----------- --------------_-__-_-_-----.-_- Water Supply: Public system ❑ Community system ❑ Private [?--Depth to Water Table --- _ ft Character of soil to a depth of 3 feet- Sand E] Gravel ❑ Sandy Loam ET' Clay Loam E] Clay E] Adobe ❑ Hardpan � Previous Application Made: (If yes,date- -------- --- ) No ❑ New Construction: Yes ❑ No ❑ FNA/VA: Yes ❑ No , TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic .ank: Distance from nearest well_.,;_._f-Distance Distance from foundation fo_undation-___A�_-_-_--_.Material. �- - No. of compartments___.- _y --........Size---? S.-�- Y.SLquid depth-__� ' ._---- CaPacitY-1.-_G5 Disposal Field: Distance from nearest well___50...Distance from foundation.....Lp.(__.__.Distance to nearest lot line. -/- .... El"" Number of lines -------------`Y..._..__------Length of each line-. __�......_....._...Width of trench._.Z_'.______._..--------------- Type of filter material------ 5,eg!----Depth of filter material.../Q.' .._._.___Total length______/d�-_----------------------_ K /' N / See pa e Pit: Distance to nearest well ........Distance from foundation----/iP_-----__.Distance to nearest lot line__..,,---------- 1 Linin ± -r-----. .8iale#er... .�/ .-� -- /.-.o- r �"� Number of pits... ____.�':.._._._ g material.- Size: Depth...... i • t Cesspool: Distance from nearest well ----------------Distance from foundation...... ❑ . ;Lining material------------ _ ._--_.._----- -----. _ � ----9als.Size: Diameter- -------- - --------.De th_--------- - -------------- �___ ......._.Li Liquid Ca acitY Privy: building ^.� Distance from nearest wet--------------- -------------_._...___.____..__Distance from..nearest building_______--___-.--.._----------._.______._. ❑ Distance to nearest lot line ______________________---.._ I I { - -------------------------------------------------------------- Remodeling and/or repairing (describe): i --------------------------------------------=---------------------------------�---------------- --------------------------------------------------------- --- -- ------------ ---- ---- -` ------- ------------ --------------------------•--------------------------------------------------•----------------------------------------------------- ------------------------------ ----------------- - ---------- - --------------------------------------------------------------------------------1------------------------------ ----------------------------------------------------------------------- ---- 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 San Joaquin Local Health"District. ' � I [Signed} = and/or Contractor) Bk ---------------- ---------------------- ----------------------- (Plot plan, showing size of lot, location of system relafion to wells, buildings, etc., can be placed on reverse side). FORDEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- DATE f ^(`° --- REVIEWEDBY.-------------------------------- ---- -- --------------------------------------;--------------------------------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED------- -- ---- - DATE----- --------------- - - Alterationsand/or recommendafions-- ------------- ----- ................... -- --- -------------------------------•---------------- -------------------------------------------------- a. ---------------------- ------------------*------------------I----------------------------•------- ---------------------------------------------------------------------------------------------------- --------•------------------ ._. - Date ./_J _ "'.. ---------------------------------- FINAL INSPECTION BY:.....- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.lfa:ellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi, California Manteca,California Tracy,California E.H.9 2M 1.67 Vanguard Press - !