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OR OFFICE USE: VisJ' ------------ - 4- - -_ APPLICATION FOR SANITATION PERMIT Permit No_ _______ ------------------------ ------ -- ------- -------- ! (Complete in Duplicate) ani la Date Issued --------------------------------------------_----------- This Permit Expires 1 Year From Date Issued � T Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the woWhe ein described. This application is made in compliance with County Ordinance No. 549. l� a JOB ADDRESS AND LOCA Tlele ----------------------------------------•------------ , J � S -------------------------------- Phone-------�-�---•-----------•--- Owner's Name= E Address--------------------------------- -----------------•-----------•--------•--- Contractor's Name-------------------- ------ -e Phone.. ,0_��.© Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ � Number of living units: __/--- Number of bedrooms _. _ Number of baths _1.._. Lot size __.--- +2��-- ..Trsr--------------------- I Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [ta lay ❑ Adobe ❑ Hardpan p Previous Application Made: (If yes,date-----------_--------I No New Construction: Yes eNo ❑ FHA/VA: Yes ❑ No [N-1 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) e � Septic Tank: Distance from nearest well--------_-----Distance from foundation-_ -- ------------Material --_____________ l�r No. of compartments--_----�—.------------Size__ /-Liquid d _..� epth____ f_.---..___-Capacity_y�__ j Disposal ield: Distance from nearest well...... --------Distance from fou"ndation__ _ .__--_.Distance to nearest lot line_____-.�_____.____. Z J Number of lines`_ `r_____ __ --- --------------Length of each lin� y. - 5`.Width of trench---- - `�----------------- i9 .0e r Type of filter material--- /�� Depth of filter material_. ----- Total length------j�___------------------------- Seepage it: Distance to nearest well_________ _________Distance fro foundation__114_________.Distanc to nearest lot line_--- --------__. Number of pits-------I------------Lining material---S�l9Le.1r__S¢e: Diameter_ ......Depth_._� _____________ Cesspool: Distance from nearest well-----------------Distance from foundation---------- ---------Lining material-------------------------------------- V ❑ Size: Diameter- 3---- --------- -------------------Depth----------------------------------------------------Liquid Capacity_.-----------------------gals. i Privy: Distance from nearest well Distance from nearest building g ❑ Distance to nearest lot line----------------------------------------------- ------------------------------------------------ ------------------------------1-------- cA Remodeling and/or repairing (describe):--- �•--- ----- -� 1 ,/=•c• ----------------------------------------------------- ------------- N. i I I -----=--=---------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------ - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I ordinances, State laws, es and regulations of the San Joaquin Local Health District. (Signed)------------------------ F)`'' wner and/or Contractor � a - ---- --------------------------------- By (Title} (Plot plan, showing size of lot, location of syste �inrelation to wefts, buildings, etc., can be pl re-don reverse eI. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_____________ __ _ DATE___U---3-?__'—--- -------------------- REVIEWEDBY----------------------------------- ------------------------ --------------- ---------------------------------------------- DATE---------------------------------------------- - BUILDING PERMIT ISSUED--------------------------------------------------- ATE-- --------------------------------------- ----------------- - ------------- -- Alterations and/or recommendations:- �. �7•�--------- - �`'----�� --- -------------- --------------------------------------------------- -•----------- ---------------------- -----------------------------------------a -•-- ----------- --------------------- ---------------- ------02------_ - -------- r v (-------------------------------------------------- --- --- ------� ---------------------------------------- - ---- -------- -- -------- --- ------------------------------------ ------ ------------------------------ = - -------------------------------------------------------------- i FINAL INSPECTION BY:----- �- ----------- Date---------57-25 w-- 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 s� ,