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' FOR QFFICE USE: S- -- --_ ________________ 7 APPLICATION FOR SANITATION PERMIT Permit No. ...!:d ?...�........ •: ' ------------------- ------ :: --------- {Complete in Duplicate) `� This Permit Ex i4s. 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 rdinance No. 549. / /, JOB ADDRESS D LOCATION ` 7 a i --------------------------- Owner's Nam • -=---=------------ ---------------- Phone_._-..__... � I ; - Address..... -- _.._ = Contractor's rName ; --------------=---------------------------------------•--------- Phone................................... Installation will serve: Residence gr Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other ❑ lNumber of living units: __j____ Number of bedrooms JNumber of baths -_2.-. Lot size ----7S'x-1.1-0---__--- Water Supply: Public system ❑ ySommunity system [3--Priva to ❑ Depth to Water Table �.T--- ft.Y Character of soil to a depth of 3 feet: Saeid ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Q- Hardpan ❑ Previous Application Made: (If yes,date____________________) No ❑-- New Construction: Yes ER—No ❑ FHA/VA: Yes ❑ No [el TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank'or.cesspool permitted if public sewer it available-within 200 feet.) Septic Tank:: Distance from nearest well_________________Distance from foundation--------------------Material____________---- ---_________-_____.___.________- /b►�yiC No: of compartments Size -------------- Liquid depth -------Capacity-----------••------•--- -----------------------. Dis al Rield: Distance from nearest well__----------------Distance from foundation--------------------Distance to nearest [of line_______:....___.. . p � �19 Number of lines-----------------------------------Length of'each line------------------------=---- Width of french------------ Type of filter material-------------------------Depth of filter material-------- ---Total length----------------------- Seepage --------••-:_-_-_-------•-•-- . _ Distance topnearest welLti�_--------_Distance from~foundation__i�./___..__.__.Distance to nearest lot line.__ �_�-....__ ` p .. Nu ' f tuber of,pits ------'Lining matenal �_��s�.f_----.Size: Diameter----•-Z3__,-----.Depth-----a_��'..--_••---------- ee a e Pit: Dis Cesspool: Distance from nearest well__ .........._.....Distance.from foundation---------.___:----lining material--._______________-__-.-________ 1 ❑ Size: Diameter = = ----------- Depth -----7---Liquid Capacity-----------------------------gals )�, Privy: »I Distance from nearest well ______________________ _ _______________Distance from nearest building__-_---_________________..__________..._. a Distance to newest lot line------------ __ Remodelin l g and/or repairing (describe): - - ------------------------------------------------- ------------------------------------------------F------•----------••--•------•---------------7-------- ------------•-------- ...............-............... ..- = - I ------------------------- •------------------------------------------------..---------------------•-------------------------------------------- --------- I hereby cerfify That f have prepared Phis application and that the work will be done in accordance with San Joaquin County ordinances, State laws,`and rule a9d regulations-of the San Joaquin Local Health District. (Signed)------------------------------------ -- ------------------------------------•----------------------------(Owner and/or Contractor) BY: ------------------------------ ------------•----------:--- --„------------•----------------------------------------------- -------------ITitle)--- ------------------------------------ -- -- -------------- (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 BY------ L= lici -, :�M---------=------------------------------------------------------ DATE----- ------ -- --4---ff° I REVIEWEDBY----------------------- ---- '-------------------- --------- --- DATE BUILDING PERMIT ISSUED-----•--------------------------------------- ----------------------------------=--- ------ DATE Alterations and/or recommendafions:-�_:_______________ . -- - - -- ----------------------- ----------------------•--•---------......---------•----------•---•----•----••----------------••---------- �_ HC'�:_iC ti--------=-� '- -- ------------•-------- -----•------------------ ;-----------------------------•----- t . ---------------- --------1----------- ------ -------- ----•--.---- FINAL INSPECTION BY:. . -- r Date..... .. - � -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stocktonr California Lodi,California Manteca,California Tracy,California E5•9 REVISED 0-59 F.PICC.ZM 6-6e