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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ._�r?G .a --------------------------------------------------------- / ---- -------------------------------------------- (Complete in Duplicate) Date Issued `-1 - �C� ----------------------------------------------•------._-- This Permit Expires 1 Year From Date Issued /10� Application is hereby made to the San Joaquin Local Healfh District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 544. JOB ADDRESS AND LOCATIO ? �� ;� A -c.��"C° Owner's Nam Phone .----------- -- -- -- --- Address i r ----------------------•----------------------- , Contractor's Name---------- ----- - ��-- ``� Phone Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other 0 Number of living units: ___1--- Number of bedrooms 3____ Number of baths __1--- Lot size ___--. �___________.__-_ Water Supply: Public system ❑ Community system ❑ Private [Depth to Water Table -------- ft. Character of sail to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 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.) Sepc a tink: Distance from nearest well____�.9_.p__"-Disfan e from foundation_____ a__�_...Material-_____- ___._ _ _____._ _-__-- .......... [ No. of compartments_____ _________._Size_ Y'�(5_'X_5. .Liquid depth-------41. ...........Capacity.... �ao e� Disport l Field: Distance from nearest weli___,�� _____-Distance from foundation....Lh_.._____.Distance to nearest lot line-5............ Number of lines-------------I-------------------Length of each line------ Oi ---- _________-Width of trench-.-.-X------------------------- Type of filter material--------%LRL------Depth of filter material-----1_.4_.�...-.--- Total length-------a!-pa=----------------------- � Seepa a Pit: Distance to nearest well_.___._ 490__ Distance fro foundation_____1P-_�---- Distance to nearest lot line----- S-f---. Number of pits---------y_____Lining material-_v�� ----- Size: Diameter-------3-3_pf-----Dept h......9-_S__'--_________-___ 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 (descr;be):---------------------------------------- --------------------------------------------------------------------------------------------------------------- -----------•------••-----•-----------------------------------------------------------------------------------•-------------------------------------------------------•-----------------------------•------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------- ---------•----------------------------------- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, les and regulations of the San Joaquin Local Health District. (Signed)----.------------- ------- ------------- - ------------------------------------------ �id/or Contractor) By:------------- ----- -----------------------------------------(rifle)---------- ------------------ - -------..----. ------- (Plot plan, showin 'ze of lot, location of system in relation t wells, buildings, etc., can be placed on reverse side). FQR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- - - ------------------------------------------------------ DATE 1P'`L_4&------ -- ---------- ----------------- REVIEWED BY---- - ---------------------------------- -- ------------------ DATE----------------------------------- -- ----------- - ---- -------------------------------- ----- --------------- BUILDINGPERMITISSUED-------------------------------------------------------------------------------...-------------------- DATE----------------------------- Alterationsand/or recommendations----------------------------------- --------- --------------------- -----------•----------------------------------------------------------------••------------ -------------------------------•---------------------------•----------------------------------------------- --------------------------------------------•------------- ----•-------•---------------------------------------- ------------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------- ----------------------------------------------------------------------------------------- -----------,---`------------------- ------------------------------------------------------- FINAL INSPECTION BY:. --------------- Date' 1- - 'r` -------------------------------------- SAN - - --------------------------------- 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.Cp.