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FOR OFFICE USE -- � _-----7 � ----------- / ----- -----------7---------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. . .1}.��..1... -- ------------------------------------------------------ (Complete in Duplicate) - This Permit Expires 1 Year From Date Issued Date Issued .________ 4_ 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 ----�-- ---2---------a Ate ! •-------- Owner's Name---- --- - --• -- �'t - —--------------------------------------------------- ------------------ Phone------------------------------------ Address lz `r:�•• -------- Contractor's Name_-_-_--�� r Installation will serve: Residence ��Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _L!__ Number of bedrooms ---�L Number of baths _-.I__- Lot size -------------------------_---__ Water Supply: Public system ® Community system ❑ Private ❑ Depth to Water Table ---------ft. Character of soil to a depth of 3 feet: Sand [-] Gravel E] Sandy Loam E] Clay Loam El Clay E] Adobe ti—Hardpan El Previous Application Made: (If yes,date------------------_) No 99' New Construction: Yes &�Lqo ❑ FHA/VA: Yes ❑ No J�3— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.)j 11 t Septic Tank: Distance from nearest well-_Iu ---__-Distance from foundation-lft--r------------Material---� ------------------------------ [ No. of compartments=----Z.-----------------Size----.r -YS-4'9---------.Liquid depth----.-k-----------------Capacity._8"C1PT Disposal Field: Distance from nearest wellTt,�,P_.__Distance from foundation.J.C�. ---.Distance to nearest lot line_c5-r_-_-_-- th T Number ebof filter material ___-__-_Depth off filter h mlater a7 _ Width of trench___ ---------------------------- Type :_`------------------- Yp - p A..Total length-._.,5-0-------=--------•-•------------- Seepage Pit: Distance to nearest well_ ---------Distance foyndation_/R_,x---"-.Distance to nearest lot cine rr n Number of pits----- ---------------Lining materia- Size: Diameter----.,33-----------Qepth------o ---••---------- � Cesspool: Distance from 'nearest well-----------------Distance from foundation--------------------Lining material--_.-----_-__-_----_-----_--__-----_-. ❑ Size: Diameter-I---------------------- ------Depth---------------------------------------------------Liquid Capacity----------------------------gals. 1�3 Privy: Distance from nearest well------------------r------.- _-___-..-___.-_-.-Distance from nearest building----------------------------------------- - ❑ Distance to nearest lot line-------------------------------------------------•---•------••----•----•--------------- Remodeling and/or repairing (describe___________------------------------------------------------- I t V ----------------------------------------------------------------------------------------------------------------------------------------------------••-_-__-_-___-_____-_-...._....-----_-___--__------___-_--_-_--__-.-____-.- ` I hereby certify that I have prepared f is pplication and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and re at' ns of the an Joaquin'Local Health District. (Signed) -- - ----- -------------` -------•------------------------------• -----(Owner and/or Contractor) By:---------------------------------- ----•--•---------------------- - ------------•--•-•---------------------------- {Title) (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 ' APPLICATION ACCEPTED BY---------- 1~ - ----------------------------------------------------------- DATE-------- REVIEWED BY ----------- RATE ' BUILDING PERMIT ISSUED-----•--------------------------------------------------•-----------------------------------------._. DATE----------- Alterations and/or recommendations---------------------------------------------------------•---•--------------------------------•-•-•--------------------•------------•----- 1 � a -------------------------------------- ---------------- ---------------------------------------- ----------------------------------------•-•--• •------------------- --------------•----------------•-•------------- I FINAL INSPECTION BY:------ ... ---------------------- � f --------- Date---------�--...�-- --- -- ---- ---------• -----------._...-•------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,Callfornta Tracy,California C13-9 REVIaEO 9-59 r.P.co.TM 6-6c