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FOR OFFICE USE: Q l ----------------------------------- - APPLICATION FOR SANITATION PERMIT Permit No. --------------------------------------------- (Complete in Duplicate) Date Issued This Permit Expires 1 Year From 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 Courlty Ordinanc .X549. JOB ADDRESS AND LOCATION - 64�� 1 Owner's Name /�V. ------------------- ------- hone ---- - --- - - t -- Address__ /� 7 _�� t ti( L�. -` ------------- -��-------- - - t / E. .. Contractor's Name--------------------------- •----------- ........ Phone...................................Installation will serve: Residence R---Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms ---I--- Number of baths I---- Lot size -------------�-0- --------------- Water Supply: Public system ❑ Community system E__Iprivate ❑ Depth to Water Table .-.----- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 0--,C'lay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date----------- --.-) No New Construction: Yes ❑ 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 T nk: Distance from nearest well-- arlDistance frp� four�atii`o�.n_./Q------------ _Material_ __-. _--.-----_ -... No. of compartments..-___�.---._-__-Size_��9.__ ��_. @ {u depth--------r-e- ----_-Capacity....J10-1jL2_-. Disposa field: Distance from nearest well-/-(1tt01C._Distance from foundation.- ZT---------Distance to nearest lot line_......... EK Number of lines.... . Length of each line--- .oZO__�1OV�/idth of trench .. ,y2 - Type of filter mateytaL----- Length _ _ -. pth of filter material_--le-------------Total length.____.-t�1r1_-_-_-__-__--__---_-.-__.- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- 1771 Number of pits----------------------Lining material_ Size: Diameter-------------------.---Depth-_._-_---__-__--_-_.-.-_.--_ �1 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):---------------------------------------------•---•-----------------------------------•------•---------------------------------•------------------------• �O ----------------•-•------------------------------------------------------------------------------------------------------•----------------------------------------------------------------------------- --------------------- --------------- ---------------------------•------------------------ -----------------------------------------------•-------•-------------------------------------------------------------•-------------------------------- ------------------------------------•------------•------------------------------------------------------------------------------------------------- -----------------------------------------------...-.---------- 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 egulations of the San J in Local Health District. (Signed) �4 ---'`-------- • - - ----------------------------------(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 BY---------------- ----------- ------------------------------------------- -------- -- ---- -DATE------------------------------------------------------------ REVIEWED BY-------------------- - -- -- � - BUILDINGPERMIT ISSUED---------------------------------------------------------------------- r----- -- ---- ----- DA --------------- -------- Alterations and/or recommendations------------------ ------------------------------------ ---------------------------------- -------------------- ------------.------------ -------- r ---------- ---------------------------------------------------•-- --------------------------- - --------------------------------- ----------------------------------------------------------------------- -------- --------------- --------- ------------------------------------------- - ------------_- ------------------------- -------------------- ---------•---- ------------ ------•_----------------------------- ------------------------------------- -- ----- ----------------- ---- ----- -- - ----------------------------------_-•----------------.--------------------•------------------------------------------------------ FINAL INSPECTION BY:----- -_ .__.- �` _.-_ Date-.----------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.0 O.