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FOR OFFICE USE: - APPLICATION FOR SANITATION PERMIT Permit No. _..,1..L 4...�.. ---------------------------------- ---------- C� ------------------------------------------------------- (Complete in Duplicate) L / Z- 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 County Ordinance No. 549. JOB ADDRESS AND—yLOCATION. ��' ------• --------•-•-•---•-•••-•----------------•-- ....... Name---------/_!1 `© � - ....... ••. ............................ Phone....................... Address ------- ---- -------------- -`®------------------------------------------------- -- ...................................................... Contractor's Name---- ----•--•• -•----- --- -••--••. -••••-•--•------------------------•--•--------•-•-••-•---•••-••--•-----.............. Phone................................... Installation will serve: Residenc �.4 Apartment House ❑ Commercial ❑ Trailer Court C] Motel ❑ Other [3" ' Number of living units: ...._�_ Number of bedrooms ___� Number of baths ____�_ Lot size _�_-__._____,�....1_f��....__�..�_____-t___________ Water Supply: Public system ❑ Community system Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam NClay% Adobe C] Hardpan C]Previous Application Made: (If yes,date____________________) No x New Construction: Yes o ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public s wer is available within 200 feet.) Septic Tank: Distance from nearest well__ ___ ____ ' tanLge from founda�ty'pn----�__Q........Mat riAl___. •. No. of compartments_.-•_-_��__.'_----_--------Size... Liquid depth....... - Capacity/.;?et ?._ate_ Dis o al Field: Distance from nearest well_--._ istance from foundation... ...........Distance to nearest l'ot/li e1iaS_________ Number of lines------- -�__V____�ength of each line__I Z-Off-'-Width of trench ----4-§ �y�, ---------------•-- Type of filter material_ / !` -?___Depth of filter material_�,__�L`_______Total length___.�Q______________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line---------_....... v ❑ Number of pits______________________Lining material-----------------------Size: Diameter-----------------------Depth................................. Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material---------............................. ❑ Size: Diameter--------------------------------------Depth.....................---------....................Liquid Capacity............................ Privy: Distance from nearest well-------------------------------_-----------------Distance from nearest building------------------------------------------ F-1 Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- .o�-- Remodeling and/or repairing (describe):------ P d --------------------------------------------------------------------------- -- --•-----------------•----------------------------------- •--- ------------------------- w ---------------------•------------------------------------------------------------------•--- -•--•--•--•-•-•--••---------•- ----------••---•--••-• --••••••---•---------•--••-• --- - \� -------•------•--------------•--------------------------- •-------------------------------- ---------------------------•-----------------------------------•------------------------------------------•-------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances tate laws, anA rules and regulations of the San Joaquin Local Health District. (Signed)----W "N----------------------------------------------------------------------------------------------------------------(Owner and/or Contractor) By: ,. ----e�ation --------------------------------------------------------------------------------(Title) ----------------------------------------------------- (Plot plan, showing size of lot. of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------------ DATE-----------•--------------.................................0 REVIEWEDBY----------------------------------------------------- ---- --- DATE 1�a� •�_f-yam_-_--•-•---•-•------- BUILDING PERMIT ISSUED............................ -- ----------------•---------- DATE............................................................. and/or recommendations------------------- ------------.............................................................. ---•--••--•------•---------- --•----- ----------------------------------------------------------------------------------------------------------------•-•--•-•-•••---•---•------•-•--•-•----••----------•----••--••••----•--- ........................................................ ------------------ ----------------------------------------------------------••__-------•-------•-------------_-_-----------_-__------------------------------------- -------------------•--•----------------•----- ................•---------•-------•-••---------••-----•---------------...•----------•••---•--•------•-•--•---- 2-F/ 6 Z- Date =-- ----------------------------------------------------------- FINAL INSPECTION BY:. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast Oak Street 124 Sycamore Street 205 Wast 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES-9 REVISED e•69 r.P.CD.2M 6.60