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FOR OFFICE USE-,,,;, - --------- APPLICATIQN FQR SANITATION PERMIT ------ -- -- --------------------- Permit No. ,O..,2 ----------------------------------------------- -------- (Complete in Duplicate) Date Issued ................---------------------------------_- - This Permit Expires 1 Year from Date`-Iisued" 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, JOBADDRESS AND LO TION------ ---- a _ __e- --------------------------------------------------------------------------------------- Owner's Name---------------16-Y -- ------------------ -----------------• --- phone.__------------------------------ Address---------- - Contractor's Name _'�34? Phone Installation will serve: Residence [11,--Xpartment House ❑ Com er ipl,f❑ Trailer Court ❑ Motel. ❑ Other ❑ +vvv ! Number of living units: _-- Number of bedrooms , --+ um er of baths A---- Lot size ---------------------- � r Water Supply: Public system ®/Community system ❑ Private ❑. Depth to Water Table -------- ft. 7i Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If es,dote--------------------1 No ' New Construction: Yes No FHA/VA: Yes ❑ 'No ❑ PP Y ❑J ❑ ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation_----------------.Material----. -------------- --------------------------- �j` l fOY No. of compartments Size Liquid depthCapacity... r Disposal Field Distance from nearest well---SD-.......Distance from foundafion_J_ --------------Distance to nearest lot line__---------- Number of lines----------I------------ ----------Length of each line------ Width of Type of filter mate ria 1_1 2_4,J_Depth of filter material;._.j�_-�__......_Total length----------- ------------------------- Seepage Pit: ` Distance to nearest well-------=--------------Distance from foundation--------.-----------Distance to nearest lot line--._---_.- [] Number of pits---------- Lining material-----------------------Size: Diameter-------------_---------Depth.......k_.--_-_______-________._ G`I Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---..----- -------------------I_-._. ❑ # Size: Diameter-------------------------------------Depth---------------------------------------------------Liquid,Capacity----------------------------gals. Privy: {� -"Distance from nearest well-------------------------------------------------Distance from nearest building-------------- __-________-------____._. ❑ Distance to nearest lot line. ------- ---------------- ------------------- = - - ' k y# Rem delin� and/or repairing (describe : ,;----- - ---- ----r `°G ��' i-- -= � 1� a r--- --_- _ ------------- ---------------------------,----------------------------------------------• ------------------------------------------------------------------- --- --------- --------------------------- = ---- . , . ------------------------ ------------------------------------------------- --------------------------` I hereby certify that I have prdpared this application and that the work will'be done in'accordance with San Joaquin County ordinances, State la and rules o1 regulations ofaheESan Joaquin Local Health District, r (Signed) = ; -- ------------------------------------------------------- ----- (Owner and/or Contractor) By:.------------------------- L�------------ ----------------- - ------------------------------ (Plot -9 ------- (Title) � ) (Plot plan, showing size o I ocation ofsystemin. relation to wells, buildings, etc., can be laced on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------- ---------- ------------- --------------------------------------- DATE----- REVIEWEDBY------------------------ ---------------- --- -------------------------------------------------------- DATE------------------------- ----- BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------- --- --------- DATE------------------------------------ - ------ --------------- Alterationsand/or recommendations--------------- --------------- ---------------------•----------------••-----------------------•-•--------------------_--------•------------------------------- t ---------------------------------------------------- •----- ------------------- ------------------------- -----------:---------------------------------------------------------------------------------------------------- ----------- -------------------- --------- ----------------------- -------------- --------------•------------------------------- ----------------------- --------------------------------------------------------- FINAL INSPECTION BY:------..... �. ---------- Date--- _ / ---------------------- SAN JOAQUIN LOCAL. HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 west 9th Street Stockton,California Lodi,California t Manteca,California Tracy,California' " F.P.eo.