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FOR OFFICE USE: -- ----------------------------- ------------------------ ----__ . ___----__---------._ APPLICATION FOR SANITATION PERMIT Permit No. S.U•...7.- ------- -------------------------------------- ------ (Complete in Duplicate) 1-61 -------------- ---- -------- - --------- --- ------------ This Permit Expires 1 Year From Date Issued Date Issued ._ �.f� Application is hereby made to the San Joaquin Local Health District for a permit construct and ins# 11 t wor h, ,i cribed. This application is-.madenin_compliance with County Ordinance No. 549. E �J f �. La-, E:x . JOB ADDRESS AND LOCATION- - _ __- -_� . ,j____ --- -- --- ----- - -------------- Owner's N e __ Addresi Contractor's Name--- -- ------------------ - -�-- � - --------- - -, .1�---.-.--------------------- Phone ��---_ Installation will serve: Residence `Apartment House Commercial ❑ Trailer Court ❑ Motel [:1 Other ❑ Number of living units: __/___ Number of bedrooms ----- umber of b the __ _- Lot size ---6-6 Water Supply: Public system E] Community system El Private epth to Water Table _.------ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel r] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: (If yes,date------ ) No ❑ New Construction: Yes ❑ No HA/VA: Yes ❑ No ❑ + TYPE INSTALLATION AND SPECIFICATIONS: ¢ No septic tank or cesspool permitted if public sewer is available within 200 feet.) e ti Distance from nearest well-----------------Distance from foundation- ------------Material.-.___-----.__--_-.._-----___--_.____ ___ o. of compartments------------ ------ ----Size--------------------------------Liquid depth-_------ ------------ Capacity_ _ ;eld• Distance from nearest well - __-_--- Distance from foundation---45_ Distance to nearest lot line_t��, h Number of lines-------___ ---------------- Length of each line-____----` ------.Width of trench� :A P� '° " -------------- Type of filter material --- - Depth of filter material---.._�- -__--.._Total length_--__-_-�-�--------------":� 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------------ ..Linin materia).____--__--_-_____-_----___-_.._.__- ❑ Size: Diameter--------------------- --- - -------Depth-------- ------------------------- -----------------Liquid Capacity gals. r.._ — Privy: `� Distance from nearest welt___________________-------- -------------Distance from nearest building --------------- _______ __ - . istance to nearest 10! line- _.__--_.- __________________---------------- Remodeling and/or repairing (describe):--.`'It __---. ------------------ -------------------•----------------------- - ------------------------------------------------ ----------------------------`----'---'------ ---------•-------------------'-------------------------------- ! I hereby certify that I heve,.prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat~ a s, nd rules 'and r gulations of the an Joaquin oval Health istrict. (5i ned \ 9 } ::r L � "--- ----------- -(�w�a or Contractor) _ - ------ -- ------------ $Y�-----------------------------------------------�------------- --------------- -- � Title ------- - - { } --------- ot plan. s owing"size of lot, location of system in relation to ells, buildings, c., can be placed on reverse side). g FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------- ------------ DATE------ ---- - -- ------------------------------------ ------------- --------------------------- ---- EVIEWED BY DATE - u ------------------------------------ I PERMIT ISSUED----------------------------------- ----------------- - -•------------ -------- ------- ------- DATE-- --------------- ------- ---------------------------------- Aaerations and/or recommendations:------- . --------------------------------------------------------------------------------------------------------•-•------------------ ---------------- ------ ----------------------------------------------------- ------------------------------------ -------------------- 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,cCalifor rnnia r F.P. o. _/2' �.�? ga.1��