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FOR OFFICE USE: " APPLICATION FOR SANITATION PERMIT Permit No.,.,/7.__ ---- ------ ------------------------ -------i1 �. _ I (Complete in Duplicate) Date lssued_�VAe _.- t 1 ' --- -- -- This Permit Expires 1 Year from Date Issued >a � _ 4- - Application is hereby cnida to' San Joaquin local Health District for a permit to construct and install the work here n described. This-application is made in compliance with County Ordinance No. 549. a "z �� yy�, ---------------- JOB ADDRESS AND i_OCATION____'l_. ` ----- --�'----"-'-------- ' - - - - -------- ----- ----- - ------- - - --------- Phone Owner's Name-------- 41� ---- - ... 1 -a•f------------------------ Address---------------- - ----- ----- - -- Contractor's Name__.;C -4c-------- •------------•--------------••---------- Phone--------------------------------•-- I! Apartment House Commercial ❑ Trailer Court Q� Motel ❑ Other ❑ Installation will serve: Residence ❑ p ❑ > Number of living units:�_______ Number of bedrooms -------- Number of baths -------- Lot size s /'" ''� ------------------------ 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 [IClay Loam E] Clay Hardpan Clay ❑ ❑ ❑ Previous Application Made: {1f yes,date______ _________} No [3 New Construction: Yes [I No ElFHA/VA: Yes El No 1 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) - i Septic Tank: Distance from nearest well_________________Distance from foundation-------------------:Mater ia------------------------------------------------- Capacity _______-____.____ _________---._._._____- Li Liquid de th_------------------------Ca acit ❑ compartments--------------------------Size----------------------I----- q p. p Y Disposal Field: Distant 'I No. o I:rom nearest well_._:��-:�-"-Distance from foundation___��'------Distance to-nearest lot line_- ��--_. Distance fer rom lines - Length of eaC' � line --- 0.----- -----------Width of tren h r ------Total length__6_Q1----------- ------- Type of filter mater�al/�_ f> ---Depth of filter material___-"� - Seepage^Pit: Distance to nearest well-----------------------Distance from foundation------.-------------Distance to nearest lot line______._.-______ ❑ Number of pits----- Linsnc� material----------------------Size: D,iameter--------------- -----.Depth--------------------------------• 4 Cesspool Qistancelifrom nearest well_-______.__.____Distance from foundation__"._-_-__.--_____.Lining material_______________._..---__.________--. Size. Diameter---------------------------------------Depth---------------------------------------------------Liquid Capacity-- ------ ---- -- gals. Distance:from nearest well ---------------'�-------- ---------- Privy: __=_ Distance.from nearest building_ -�-' - � •-- - { ❑ to nearest lot line__..---_--_ - elfin and or re airin I ) a � i '�" { -- ------- stance.� - Remod describe g / p 9 I {� : i ----- qr k ---- ----- ----------------=- --- ------------------ ----- ------- ---- --------------------------- - 4 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. -------_--__._____(Owner and/or Contractor) (Signed)_ - - - _ L.:. .. - b o -.- (Title)---•------ �----------f'------- -------- - ------ -- ` 4iAg_" --------- -------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells,.buildings, etc.,-can.be placed on reverse side). FOR DEPARTMENT USE ONLY CCEPTED I!BY - ------------ DATE__ . r J �� - APPLICATION A l ' -- :• DATE ---------------------------------- REVIEWED BY--------------------- ! --------;--------------- - ------------------------ ------------------ DATE. -----------------------------------------" BUILDING PERMIT ISSUED-q__._------------------- ----------- ----- _ _ Alterations and/or recommendations: .- ------ ------ - ------- - i ------------ --------- -----•----- ---------------- ------------------------- ------------- -------------------"-----•-- ------• ------ -- ----- --•--------------------- ---------------- . -- ------"----------------- - ---- ---•-"=-------•---- ------------- -----•------ ----- - fp - FINAL INSPECTION BY--' e4 - -• -_ -------------------------- Date_... _ SAN JOAQUIN LOCAL HEALTH DISTRICT G� s 1601 E.Hazellon Avo I 300 West Oak Street 124 Sycamore Street w + 205 West 9th Street Stockton,California I� Lodi,California Manteca,California Tracy,California I ES 9 pEVISEG 8-59 3M 3-•631I,r.P.CC. MF it 1