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FOR OFFICE USE: ------------- ----------.------------------------------- ------------ APPLICATION FOR SANITATION PERMIT Permit No. .�..`�.�.._ -- ---------------- -• - ------ -- --------------------- (Complete in Duplicate) -1 --------------------- This Permit Expires 1 Year From Date Issued Date Issued ......1../......... � DS.— 11-h -. St Application is hereby made to the San Joaquin Local Health District for a permit to construct and insta t e work herein described. This application is made in compliance with County Ordinance No. 549. 1`7 o Z ( ./- ..)E -� JOB ADDRESS AND LOCATION--------------------------- --------------� -- �itfc •lC� j /I u G Owner's Name ---- -------------- Phone------------------------ -- ----•-•--� -----...... -72 Address----------------------------------------------a `-•..-•---- r - •----•---- ---------------------------------------- ------------•- --- = ------------------------------------------- ------------------•-----------•--•----- Phone-------•--------------------------- Contractor's Name. Installation will serve: Residence R Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [I Number of living units: ----/__ Number of bedrooms -_3.. Number of baths;?Y-Lot size __-------_._ __t,-C) -` ............... Water Supply: Public system ❑ Community system ❑ Private ®- Depth to Water Table-5-0.. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date---. ` -,_} No ❑ New Construction: Yes IS No ❑ FHA/VA: Yes;, No ❑ 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- 6-0------Distanc from foundation-----�©---------Material___ -------------------------------------- - _. t�...._..._ No. of compartments- A ---------Size_. �!? -.Liquid de th____---- � __.--Capacityr� Disposal Field: Distance from nearest well------ d...Distance from foundation.....ZR........Distance to nearest lot line. �..... Number of lines-------3------------------------Length of each line_____---70-----------------Width of trench---------�`�� _----_ Type of filter material---Aa--k-----.---Depth of filter material-------&-"--------Total length----------�:�Q..................... p Seepage Pit: Distance to nearest well----------------------Distance 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-------------------------------- ------------ ------------------___...................................................................... Remodelingand/or repairing (describe)--------------------------------------------------------------------------------------•-----------------•-----------•----•--•-----_------------------- -- ---------------- • i• •------------------------------------------------------------•-------------.--------.---------------------------------.----------•-------------•.---€-----•-------.------.--------------.---------------------------------- --------------------------------------------------------------------------------- --••---••.•.---.--•-------- ---------------------------------------------------------------------------- _-------------------------- 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. /f (Signed) --f . / (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 BYff• -- ------------------------------- DATE------------ �. �_. REVIEWEDBY----------------------- - --------------------------------------------------------------------•-•---•-••-•---.... DATE--------•---•---- -------------------------.........------- BUILDINGPERMIT ISSUED---------------------------------------------------------------.......................--------------- DATE--`•---------------------------------------------•--•-------- Alterations and/or recommendations:------------------------------------- ---------------------------------------------------------= -:.. = ----------------------------------------------------•----•-----------------------------------------------------------------------------------------------------------------------••-------....------------------------------- ----------------------------------------------------------..------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------ ------- ---------•--•-----•-------•----------- -------------------------------------------------------------------- ------------------------------------•- ••------------------- FINAL INSPECTION BY:-, -- -- _ =- -_-- ! . -- ---------- 7-� �- -- - --------- 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,California Tracyr California ES 9 REVISED B-89 YM 5-61 All-A9