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I-VK VI-HU USt: --- ----------------------- ------------- ---------------- APPLICATION FOR SANITATION PERMIT Permit No. -_I__(/..FS_ - ----------------- --- -------- (Complete in Duplicate) _e�{_7Z.�_-1 ---=------ --.-------------------------- ----- This Permit Expires 1 Year From Date Issued Date Issued 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 A LOCATIO ��[ _ - ---------------------- ------------------------------------------------ ---------- Owner's, Name -- _1ta-- ---------------------------- ------------------------------------------- Phone--.w�- ------------- Address;--------------------- op c. ----------------- ------------ Contractor's Name ••---- -------------•---- Phone---��_.-��T_/v Installation will serve: Residence Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ _._ Number of bedrooms _�,�__ Number of baths ZL_ Lot size ________________________________________--__.._____.____-_ Water :Supply: Public system ❑ Community system ❑ Private PIR--Depth to Water Table /U ft, Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe RH-"H'ardpan [] Previous Application Made: [If yes,date____________________) No ❑ New Construction: Yes P--<Vo ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ep Tan k: Distance from nearest well_________________Distance from foundation------------.-------Material____---_---___.______._______---..---_...____._. No. of compartments-------------------- -----Size--------------------------------Liquid depth----------------- --- - Capacity---------------------- Disposal�sId: Distance from nearest well 6- Distance from foundation-__R_--4------.--Distance to nearest lot� line�+�.-------- '� Number of lines._____________. Length of each ---Width of trench.____ y________________F_Type of filter material dG!]�.__Depth of filter mater�al-.��__!__._-_Total length________------__-_-__- Seepage Pit: Distance to nearest well---------------------- from foundation--------------------Distance to nearest lot line__.________-___ ❑ Number of pits----------------------Lining material---------------------.Size: Diameter----------------------.Dept h--------------------------------- Cesspool: Distance from nearest well--_-------------Distance from foundation--------------------Lining material______-___________________-_-_______. ❑ Size: Diameter-------- ---- ------- ----------------Depth------------------------------------------- - ------Liquid Capacity---------------------------•gals. Privy: Distance from nearest well ______-------------------_----------------------Distance from nearest building-----------------------------___....... ❑ Distance to nearest lot line---------------------------------------------- ------------------------------------------------------------------- ---•----------------------- Rem deling and/or repairing (describe):_ -------- ---- - - ------ - ------------ -- - ------ -�---------- --------------------------- ------------------------------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St,94 laws, and ryles a re ulations of the San oaquin Local,Health District. (Signed)-------- ----- --- --- --------- . -- ------- -_.(O er and/or Contractor) --------------------------- -- By:--------------------------------------------- ---------------------(Title)-- - -- - ------- (Plot plan, showing size of lot, location of system in relation to s, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY... 4------- ---------------- ---------------------------------------- DATE----- 1 ---------- REVIEWEDBY-------------------------------------- ------------------------------------------------------------------ ------------------ DATE - BUILDIt,IG PERMITISSUED--------------------------------------------------------------—---------------------------- --------- DATE----------------------------- ---- Alterationsand/or recommendations------------------------------- ------ ------------------------------------------------------------------------------------------------------------------------- -----------•----------------------------------------------------------------------------------------------------------------------------------------- --•--------------------------------------------------------------- ----------I--------------------- ------------ ------------------- ----------- --------------- ------------ ----------• - • -------------- --------------------------------------------------•------------------------------- ----------------- ---------------------------------I---I---------------- -- ------- -- ---------------------------------------------------------------•--------------------------- - ---- ------------------------------- 5 _ 5 -69 FINAL INSPECTION BY:.- .--C%6&%—"---- ---------- -------- Date---------------- ----------- ----- ------ - ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.p.CO.