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FOR OFFICE USE: r`7 !y r1 �5 V ---- - -- ---- -------------------- ----- ------- -- ------------------------------------------ -- APPLICATION FOR SANITATION PERMIT Permit No. ................. (Complete in Duplicate) _..-. 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 in No. 9 2S-2-7 I JOB ADDRESS A L ATION ` --------------- - -- - ------------ Owner's Name-------- ei Gu -1 76- Address --... Phone------- ----------- -- � -- ---------------- ------------r. - —--- -------------'------ --- --------------- n Q- Contractor's Name---- --- ------ -------- ---• ------- ------------------ Phone ' Installation will serve: Residence ❑ Apar men+ House Commercial ❑ Trailer Court ❑ Motel ❑ Other. Number of living units: ----1_ Number of bedroo scR___, umber of baths _,<_.__ Lot size ___ ___._ __ _ ____ :- -------------------- I _. , Water Supply: Public system El Community system rivafe Rr Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [T-Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------J No ❑ New Construction: Yes ❑ No E] FHA/VA: Yes ❑ No [71t � TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank orIcesspool permitted if public sewer is available within 200 feet.) f Septic Tank: Distance from nearest well__=�Q!�"Distance/from fo�unda�tisn-_/a...._._._..material----.,r .� �,. ---- �� No. o� compartments_-_-�P�------._-.`_Size�_.Tv__. __Liquid depth._.___ -�..._._______Capacity_.,�_Z9 _ t l iD__F...____.Distance to nearest lot lined -� _-_ Disposal Field: Distance from nearest weII..J;0 Distance from foundation__ []c/ 'Nbmier of lines------, '_-_--- _ Length of each line-------.��-------------Width of french----�—�-:-------------------- I �,T.ype of filter material--___sr)�_____'Depth of filter material-_--____�_ ."_._Total length____-___j�t�_.____________ _____ Seepag Pit: Distance to nearest well--- ;-�6.f _Distance from undation---.�_0_ -_____-Distance�to nearest lot he_� ------- ENumber of pits.__.________'.mining material.:__._ ,.__.Size: Diameter-------_,�. __.___-Depth----�--___________________ I Cesspool: Distance from nearest well-----------------Distance from foundation---.----------------Lining material------------------------------------- F-1 k"Size: Diameter Depth r----------------------- Liquid Capacity gals. I __Distance from nearest building t I Privy: Distance from nearest well - ----------------------------------------- 9 - --------------------------- � ❑ Distance to nearest lot line------------- ------------------------------ ------------------------------------------------------------------------------------------------ Remodelingand/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, State I rules and regulati of the San Joaquin Local Health District. 3 __- and/or Contractor) (Signed)-- ------------- -------- -- -- ----------- -- ---------- ------- - ------------------ - ----------------------- ------------------- � By:----------- - ------------r----- ----- --- -------------- - -- -----------------------------------(Title)---------------------------- --------- - -------- ----- (Plot plan, showing size of lot, location of system to relation t ells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------- ------------------------------------------ DATE---- 3 REVIEWEDBY---------------------------------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED----------------- ---------------------------------------------------------------------- ------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:-------------------------- ----------------------------------------------------------------------------------------------------------------------------------- -----------------•------------------------------------------------------------------------------------------ ------------------------------ ------------------------------------------------- ------------------------------ 13—� FINAL INSPECTION BY:..- ---------------- Date.- ---- ------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haseltan Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CO. i