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FOR OFFICE USE: -------------------/6 '--.,5-0------- ----------------------------- - -------------------------------- --- -------- ------------ APPLICATION FOR SANITATION PERMIT Permit No. r (Complete in Duplicate) �p 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 hereein4escribed. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCAT ON ,/j ,� '• -- _ _l, et9 !I _ _.tT,�r Owner's Name------- "' "`+ 'r- ---y-- - --------- ------------------- -------------------------------------------- -------------- Phone----------------------------------- "_ Address------ - ----- ..../---�i_'_�%!�_.-- _�__�__ . p- r-ove,y -------------------------------••-- Contractor's Name-- ' f r._+.: l t ---------------------- ------------------------------------------- ----------------- Phone.--------------------------------.. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/__ Number of bedrooms ,I. Number of baths -- - Lot size _________________________ If Water Supply: Public system E] Community system El Private VDepfh to Water Table _ — ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe®'Hardpan ❑ i 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 Tank; ��'/ Distance from nearest well________________Distance from foundation____...___________.Material-____...____...____________________._____-____. ,�" No. of compartments----------------- --------Size--------------------------------Liquid depth_-------------------------Capacity----------------------- 1�.. Disposal Field:-- Distance from nearest well_1.4 -Distance from foundation__ /-00-----Distanee.ta nearest [!^ # w Number of lines______ �____.____.____ Length of each line__ '� # Width of trench_ i , - - ; ---- -- Total len th_ _ Type of filter material _ - - Depth`of filter material.._._ __ length-/e Seepage Pit! Distance to nearest well ____________---------Distance from foundation.______________...__.Distance to nearest lot line_____.___________ ❑ Number of pits----------------------Lining material----------------------.Size: Diameter'----------_--_- -. --Depth_-..----------------------------- 3 .1 ' Cesspool: Distance from nearest well----------- _Distance from foundation._________________ Lining material__-.-_....____..________________.._. ❑ Size: Diameter Depth :--w--- I-*-----------Liquid Capacity----------------------------gals. `s Priv Distance from nearest well-------------------------------------- ._Distance from nearest building ❑ Distance to nearest lot line---------------- ---------- ---'"--" ------------ -- Remodeling and/or repairing (describe)------------- -----4----------------------------------------------------------- - _--------------- ` - �r ----------------r- ----------------------------------- --------------------------------------------------------- ------------- - ------------------------------------------------------------------------- t 5 ; ------------------------------------------------ ------ ------------------------ 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, and rules and regulations of the San Joaquin Local Health District. w7 k -- and or Contractor (Signed) ------------------ Ow BY: �° (Title)- --------- -- (Piot plan, showing size of lot, location of wl rn in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- - �-------------------------------- ------------------------------------------- DATE - -,5- REVIEWEDBY-------------------------------------------- -------------------------------------------------------------------------------- DATE----- BUILDINGPERMIT ISSUED-------------------------------------------------------------•-- ------------------------------------ DATE-4------------------------- ---------------------------- Alterations and/or recommendations------- ---- -------- ----------------------- -----------------------------------------------'-------------------------------------------- ----------------- t ---------------- - ---------------------- ------------- ------------------------------------------------------------------------------------------------ -------------------------------------------- - ---------------- ------------________--------------_----------------------------------------_____ ----------------------------__------------------------------------------------------- ----------------------------- �. _ w FINAL INSPECTION BY: , �,t.,[�GL�----�G2,,t�.------._. Date-- �� ------- - r . ---------------------------- a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.`Haxelton Ave. 300 West Oak street 124 Sycamore Street 205 West 9th Street 1 s Stockton,California, Lodi,California Manteca,California Tracy,California - -- F.P.CO. 1