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FOR OFFICE USE: ------------------------------------------------------ �'� APPLICATION FOR SANITATION PERMIT Permit No. . .... ................. ---------------------- ----------------------- - -- - ` -- --------------------- -- ----------------------- -- (Complete in Duplicate) 7 6 S _ --. This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work h ei escribed.1 This application is made in compliance with County Ordinance No. 549. 1 / JOB ADDRESS AND LOCATION___,?1'15/, ---iv--v/--- Owner's Name---------- --------------------------------------------------- -------- --------------------------------- Phone----------------- -------------- Address ----------------------- Q �` Contractor's Name--- ,ly ((!.__r�/L -------------------- Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ � i ___ Number of living units: I____ Number of bedrooms &2---- Number-- Number of baths _I_-_ Lot size _ . o---------------------- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table _e ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay Adobe ❑ Hardpan El Previous Application Made: (If yes,date....... ..........) No R�— New Construction: Yes gRl< ❑ FHA/VA: Yes ❑ No Eq- r TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I � Tank: Distance from nearest well-_�%-�__Distancefm foundation_-IQ________.Mateya�� - -------------------------- Septic No. of compartments___V4 ---------------Size_ _ __- -_--Liquid depth--- __----------Capacity... i ___------ I f I Disposal Field: Distance from nearest we€I__, __.._Distance from foundation_ f_2.j.____.Distance to nearest low Number of lines---------cr;-____ - Length of each line__ �7 Width of trench-,�__-------- -1" _________________ Type of filter material_ t1 epfh of filter material__, --..___Total length__-� �J______________________ i Seepage Pit: Distance to nearest well______________ ____Distance from foundation--------------------Distance to nearest lot line____-._._________ ❑ . Number of pits----------------------Lining material------------- -------.Size: Diameter.-------------------.--Depth-- ------------------------------ r Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material__.__.______-----_-_____..______-____ 7 ❑ Size: Diameter--------------------------------------Depth-------------------------------r--------------------Liquid Capacity---------------------------•gals. Privy: Distance from nearest well--------------------_----------------------------Distance from nearest building-------------._________________-_.-- -._. ❑ Distance to nearest lot line-/--�-------------------- ---W------ -------------------------- --------------------------------------------------- Remodeling and/or repairing (describe=---------- / .--- - __ --- - -- -- ----1------•------------------------------------- --------------------------------------------------------------------------------------------- - --------------- -------•----------------------------------------------------------------------------------------------------------------------------------------------------------------- I 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 frhn San Joaquin Local Health District. (Signed)---------------------- 0 ---------------------------------- By: {Owner and/or Contractor B :------------------------------------------------------------------ ----------------- --(Title)----bv,- �---- ---------.------------- Y (Plot plan, showing size of lot, location of system in relati wells, buildings, etc., can be placed on reverse side). i FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY--------------------- ------ - ------------------------------------------------------ DATE------ --------------------------------------------------- REVIEWEDBY--------------------------------------------- ------------------------------------ --- -------------------------------------- DATE----- -------------------------- --------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------- ------------------- -- Alterations and/or recommendations:. --------------------- rc -------------------------------- ---------------------------------------------------------------------------------------------------------- ----------------- --------------------------------------- -------------------------------------- ---------------------------------------------------------------------- FINAL INSPECTION BY:- ______________ '�-� --- Date------ -- �---- _(�-- -------------------------- -- ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.0 O.