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FOR OFFICE USE: } -------•------•------------------------------------------ APPLICATION FOR SANITATION PERMIT Permit No. ------------------------------------------------ -------- (Complete in Duplicate) C7 �- � Z ----- This Permit Expires 1 Year From Date Issued Date Issued ,l___________________ 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. �S r OSO- 03 JOB ADDRESS AND LOCATION.: xtt .�0 II7�Gsr ,------- r\l Owner's Name--- .. "-----------•---•-- --------------------------------------------------------------!---------------•- Phone-::.------------------ N Address ---•-- " ---- ---- ----------- ----------------._-- ------------------------------------- Contractor's Name---------- -- ----- ------- ---------- •-------- .... = = Phone.... -... ----------------------------- Installation will serve: Residence DK Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ ... Number of bedrooms _2_. Number of baths -1..... Lot size .... _------- Water Supply: Public.system ❑ Community system ❑ PrivateP. Depth to Water Table ...o_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam X Clay Loam ❑ Clay,K Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No-CA New Construction: Yes No ❑ FHA/VA: Yes ❑ NOA TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septi Tank: 'Distance from nearest wre�ll_.�D� ._Dista a fro foundation-----{-_Q_-----''...M te�i I---- --.el.--� .. No. of compartments-._.ffi.................Size �.�.��..__.__,_._Liquid depth.___�.��.--....Capacity... . ___..__ Disposal Field: Distance from nearest well__r ----Distance from foundation_._..10......:-Distance to nearest lot line ._ Number of lines..... ----------- ---Length of each line--.Ar _.....- j�::..Width of french...��__---_----.-._--.--- Type of filter meterial5f_1"#S ,,pepth of filter material....�7"------_Total length----- f ` ........................ Seepage Pit: Distance to nearest well----c Ad------Distance from fo tl i n___ [E.....f__.Distanc {to nearest lot iine..."1.__.i".._ Number of pits.-.-I---------------Lining material.. -_ meter__------�_.a_...._.:Dep#h._......A ............... Cesspool: Distance from nearest well-----------------Distance from undation---._.-_-_-_----__-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 (describe):---------------------------------------------------------------------------------------------------. ----------------------•------------------------ ,A- ------------------------------------•--------------------..---------------------------------------------------• ----• •--------------------------------------------------------------------------------------------•----- I hereby certify that I have prepared this application and that the w`ork.will be done in accordance with San Joaquin County ordinances, State laws,aandles and regulations of the San .Joaquin Local Health District. (Signed) - -- -------------- . •..... -----------------------------------------------(Gwe�ontractor) By: ---------------------- ' .° ------------.(Title} �,/ : r' (Plot plan, showing size of lot, location of syste I relation fa we is building etc., can be placed on reverse side}. a i:,. . I.�-- r.r-,* FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY--------------------------------- --------------------r----------------------------------------. DATE------------------------------------------------ REVIEWEDBY-------•---------------------------------------------------------- ------ T DATE....- � BUILDING PERMIT ISSUED---------------------------------------------------------- - -.... DATE.... ---------------- Alterations and/or recommend'ations:-_.---------------------------- - --"""'�•"" - - ------ ........... ------------------------------------------------•-----------------------------------------------------------.---------`--..-------------------------------•---------••-•-------------------------------- ---------------- .......... ------------------------------------------------ ---------•--- -------------------- FINAL INSPECTION BY:--- O Q '!F �` J---------- ------ Date ----= -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California E9 9 REVISED 0.59 2M 5-6t AILA6