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FOR O FICE USE; +- _t'_{-,f'- -------------------- --------I-------- APPLICATION FOR SANITATION PERMIT Permit No. - Z!------------------ --- (Complete in Duplicate) ------------------------------01-- Date Issued �_`.1z�---- -------------------- ----------------------------- This permit Expires 1 Year From Date Issued S�(to—I, Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This,ap.plication is made in co m liance with County Ordinance No. 549. JOB ADDRESS AND LOCAT ON---------------- --:7�__.��__Py----7I_.-- Owner's Name-----.-r Phone-------------------- ________________________________________________.__.._._ Address------------------.. Contractor's Name---------- = - - ------------------------------•--- Phone---------------------------------- Installation will serve. Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/__ Number of bedrooms _-A-_ Number of baths _/--- Lot size __ef, 'Q_______________________________ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Tablet Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam E] Clay ❑ Adobe E]--fq'ardpan ❑ Previous Application Made: (If yes date____________________) No New Construction: Yes ❑ No [ FHA/VA: Yes ❑ No E --- � 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-------------------------------------------___,_. No. of com artments-----------------------._Size-------------------------------Liquid depth---------------- - - Capacity----------------------- Disposal Field: Distancejf om nearest well.................Distance from foundation..._____-._______.Distance to nearest lot line----------------- ]1�� Number.of lines--------------------------------_-Length of each line ~ en ------------------------------Width of trench----------------------------------- � l/II , v Type of filter material________________________Depth of filter material ___.________..__.._-.Total length------------------------------------------ Seepage Pit: Distance to nearest _ --Distance from foundation__�_a__p./_____.Distance to nearest lot fine-/: ~�_._ ' �' Number of pits._.__l--------------Lining material---/I��AG.�.Size: (}iameter__3'..`"..____.__,_Depth_r��`._./�11,_�_j__-__ Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material------------------------------------- Size: iameter_______________ __ _ .____De th_______._.__.__ ._._______.Li Liquid Capacity gals. ❑ SiDp g p Y jr Privy: Distance from nearestwell_ ----------------------------------------------Distance from nearest building._______---___._______________--.._____- (C1` El Distance to nearest lot line_____________ ___ �41 - {. 4 � _ Remodeling and/or repairing (descriEe):r----- alt ------------ ------------------------------------------------- i ----------- -- -------------------------- ------------------------ F_________ -• + { a 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. _ �� [Yr -(�or Contractor) (Signed)----------------------------- ---- - -- �---�----- -- -------------� --- ----- j - - - -- ( ) ................................ (Plot plan, showing size of lot, location of system ' relation to wells, buildings, etc., can be placed on reverse side). { FOR DEPARTMENT USE ONLY APPLICATION ACCEPTEQBY --- ' - DATE f = = y REVIEWED BY ---------- ------------------------------------------ ---- ---- ------- -------------------------------- DATE------------ -----•-----------------•------ ---------------- BUILDING PERMIT ISSUED------- t^%----------------------------- ------------------------------•----------------------DATE--------------------------- Alterations and/or recommendation :----------,•--------- 10 FINAL INSPECTION BY:...... c-%-_----------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E.Haxellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California