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FOR OFFICE USE: ;A)61q LA t �U 4z ----------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. -------------------- ------------------------------------ (Complete in Duplicate) Date Issued .�a-..-�..�..� --_._-----__---_----_-__----__-__---_._-_-_---_---_- 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 County,Ordin No. 549 7 JOB ADDRESS AND LO TI N---._r...... '` /'� -- �=------- '=`-------------------------------------`'�-----�----"---�------------------_---- "Owner's Name-------------i�� " =-- i�" !. �j / -- ��nn�� t-�° ! <� ------------- --- ------------------------------- Phone Address.. �L :r .. � �` = - "�.- Contractor's Name-_----____---_-__-__� :._�: ✓_ Phone� y._�................. - ------ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ f 1- �� x a-Z----•--------•-- Number of living units: __ -.___ Number of bedrooms __�. Number of baths _____.__ Lot size � __ ._ Water Supply: Public system ❑ Community system �K Private ❑ Depth to Water Table 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 [J} New Construction: Yes [2'/No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: w , (No septic tank or cesspool permitted if public sfwer is available within 200 feet.) , �} 6 . Septic Ty�nk: Distance from nearest well_�.e�_-----Distance�frQyn fo ndlfion___.r_--_-_--_.Material_:`------------- -____.-G�_ Q No. of compartments-..-_---_2--------. Size.. __?---- k_. _ ,___Liquid depth_-_--5-- -._-...__Capacity....__ Disposal Field: Distance from nearest well._G__�47----Distance from foundation.-1`,--_--__--Distpnce to nearest lot)ine-�__-......... q Number of lines_-_-_---�---....F<,____ -----6ength of each of trench---: ._____< Type of filter material-/ -- -- - '+'" pth of filter material-._�_...........Total length-------/_---_----__f--__--.-------__- -2. Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__-_-----_-_--.-. ❑ Number of pits----.-----------------Lining material-----------------------Size: Diameter----------------- Depth_-._---.----_-_-__-_._-_-.-_ 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----------------------------------------------------------------------------------------------------------------------•-------------------- ` ) Remodeling and/or repairing (describe):----------------- ----------------------------------------------------------------------------•----•---- •----------------- 1" -------------------------------•---------------------------------------------------------------------------------------------•------------ ------ t --------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------•-------------------------------.----- 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, ind rules and regulation the Salt Joaquin Local Health District. (Signed)------------------- -----; � -t.-t/------- ). ---------------------------------------------------------------(Owner and/or Contractor) -------------------------------------(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----------------------------------------------------------- REVIEWEDBY--------------------------------------------------- ------------------------------------------------------------------------- DATE BUILDINGPERMIT ISSUED------------- ----------------------------------•----------------------------------------------------- DA ------ - - Alterations and/or recommendations------------------ ---------------------------------------•---•-------------------------------•-------------••---------------- ------------------------- -------------------------- ----------------- ----------------------------------------------------------------------------------------------------------•----------------------------------------- ----------------------------------------------------------------------------------------------------------- -------------------------------------•----------------------------------------------_-------------------.-.- -----•------------ ------------------_---------------- --------------------------------------------------•----------------------- ------------------------------------------------------------------------.-. ------ ----------------------------------------------------------- --- ----------- ------- ------ --•---------------------------•--------------------------------.------------------------------------- FINALINSPECTION BY:----- - ---- -- -------=� --- ----------------------- Date-----2------- ..... --- _��---------------------------------- - 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.CO.