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FOROFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No, 4/ AZ_/ _. -------------------------------------------------------- (Complete in Duplicate) ............. This Permit Expires 1 Year From Date Issued bate Issued 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 compliances with County Ordinance No. 549. JOB ADDRESS AND LOCATION---- 1- ........ &x`--- eT7----- sP f 3Yf1! ''' � 'Fi'�:7;i Owner's Name 1 - -------------------------------------- ------------4----- ---------- Phone------------------------------------ � ',7 e eV ----------- -- -------------------- Contractor's Name Tft--------- -' '' ~-- ....�--------------------------------------------- ------ Phone._--, Installation will serve: Residence [g- A'-partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---/'-- Number of bedrooms —Y- Number of baths --/-_- Lot size --------____---------_---- Water Supply: Public system ❑ Community system ❑ Private ©Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ SSandy Loam ❑ Clay Loam O—Clay ❑ Adobe❑ Hardpan ❑ � 5 Previous Application Made: (If yes,date--------------------] No ©/New Construction: Yes Z-<o ElFHA/VA: Yes R4 TYPE OF INSTALLATION AND SPECIFICATIONS: _._ (No septic tank or cesspool permitted ifpuewer is available within. 200Aeet.)`r _ Septic Tank: Distance from nearest well_-_____Distance from foundation_/D-----------Material--- ._. ---------------- ❑ No-.of compartments_____--_______-------___Size-b _lP-----Liquid --------Capacity__X�t- 6 / Disposa, Field: Distance from nearest well__��__ _Distance from foundation_- „;..)-/--.-.Distance to nearest lot --------- Number ---r..-Number of lines------ -------------------------Length of each linea =Gs:"t'd--? .Width of trench---- ------------------ Type of filter material-_ -/ <!�'..--Depth of filter material__/4` ____-_Total length--- ----------- � ._ .!1.. . _ T ._ Seepage Pit: Distance to nearest well._-------------------Distance from foundation--------------------Distance to nearest lot line----------------- El Number of pits._ Lining material_--------------------Size: Diameter_______________________Depth_._.__.-_________---.- 3 1 Cesspool: Distance from nearest well----------------- { fro -foundation--------------------Lining material---.--___.-__.__--._-______-__-_ ❑ Size: Diameter--------------------------------------Depth -----------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well---------------------------_______------------_.-Distance from nearest building___-.__--.-..------.-------------.----... ❑ Distance to nearest for line--- ----------------------------------------------------------------------------------------------------------------------------------------- J n Remodeling and/or repairing (describe}: �-- a--� - �-�,%-✓�`��-------------------- - ---•----.- --- ----------------- ------------------------ ------------------------------------------------------------------------------------- ----------------- --------".--------------------------------------------- ---------------------•------------------------------- t ----------------------------------------------------------------------------------•----------------------------------------------------------------------------------- --------------------•-•----------------- --------- -- ----------- --- -----------------------------------------------------•-------------------------------------------------------------I----------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State lawand-rules and regulations of theSan Joaquin Local Health District. (Signed)-------------------------- ------- y 1- ( nem and/or Contractor) By:-------------------f�= ✓ 7:C- z/-'� `- l.�r {Title} '` f; {Plot plan, showing size o lot, location of'system in relation to'wells, buildings, etc., can 6e placed on reverse side: FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------ ---------------------------=--I---------------------------------------- DATE-------------------------- --------------- ----------------- REVIEWEDBY--------------------------------------------- ---------------------------------------`----------------------------------------- DATE----------------------------------------------------------- BUILDING PERMIT ISSUED------------------------- ------------------------------------------ ---- DATE--------- ------------------------ -------------------------- Aiterations and/or recommendations------------------r----------------------- --------------------------------------------------------------------------------------------------- ---------------- ----------- --------------------------------------------------------------- �----------------------�-------------`---------—---------------------------------------------------------------------------------------- -------------- ------ -----.--------------------------------------------------------------------------------------------- -------------------------------------------------------------—------- -- t ----------------------------------------------------------------- -- ---- -- --- �."" '------------------------------------------------------------------------------------------------ --------------------'-------- FINAL INSPECTION $Y:- ----------- Date SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CC.