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FOR OFFICE USE: --------------- -elf / APPLICATION FOR--SANITATION PERMIT Permit No.Q . ----------------- -- 'Qa---- ------ ------- ---------- ------------------------------ (Complete in Duplicate) Date Issued _c5_�_��"_�� ------------------------.._ 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 herein described. This application is made in compliance with County Ordinance No. 549. 9 42, �--�------------------------•--------..-------------------------------------------------------------------- JOS ADDRESS AND OCATION_________�___- -_____ 4 Owner's Name --------------------------- - ---------- Phone-_-------------------------------- _ // ---------------•---------------•-•----- Address--- ---- d -----------•--------------------------- r Contractor's Name-- --- -awl - -----•--------- Phone----------------------------------- Installation will serve: Residence 1-1Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___]-__ Number of bedrooms 3____ Number of baths I---- Lot size ------------------------------------------------------------ Water Supply: Public system ElCommunity -system, yst em. ❑ Private [Depth to Water Table 6.0-- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[r Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ No K_�FHANA-. Yes [E�No ❑ , TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sep ' TarFk• Distance from nearest well_________________Distance from foundation--------------------Material-__-_____---__--__-_--.-__________---___--____. � � No. of compartments-- ------- -- - ---------Size--------------------------------Liquid d;pth---------- ---------------Capacity----------------------- # DisDistance from nearest •well.n!_Q___ _._Distance from foundation_ Q------------ to nearest lot line--%5 1 gLpNumber of lines......v2�------------------------Length of each line__3-0-"____-_-___-.--_-Width of trench- __,-______---__--_____-- Type of filter mate ria'I--_14d _--.,Depth of filter'material....A.............Total length----- --_____________________ Seepage Pit: Distance to nearest well---------------------- from foundation_______.. __ _ ._ n 1 ______.Distance to nearest lot line__- -____-__-- j _ ---Lining material----------.----------..Size: Diameter----------------------- ❑ Number of pits---------------- Cesspool: Distance from nearest well-----------------Distance from foundation_---------------- Lining material------------------__------------------ 171 ___________ ___.❑ Size: Diameter------ ----------------------- ------Depth-------------------------- -------------------------Liquid Capacity-------- --------gals.- Privy: als._Privy: Distance,,from nearest we{I---------------------- -------------------------Distance from nearest building-________---_________--_______-_--.--.-.-. z ❑ Distance to nearest lot kne----------------- -------- ------------ --------------------------------------------------------------------- Remodeling and/or r air g scribe) - -------- --- - - --------------- ------ 'o �.- - . = --- i gip. ------ ------ ---- ------------------- - ------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laVarules and regulations of the San Joaquin Local Health District. (Signed)_ -- -�-- -�---- ------- -------------------- -- --------------- - ----- --------- ____---._-_-(Owner and/or Contractor) - ------ -- - Title I (Plot plan, showing size of lot, location of system in relafion to wells, buildings, etc., can be plated on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_____________________ __-__. - _-- -------------------------------------- DATE---------0 - 3/ 1, .------------------ REVIEWEDBY-------------------------------- ------------------- DATE------------ ---------------------------------------------- BUILDINGPERMIT ISSUED----- --------------------------------- - ----------------------------------- --------- DATE----------------------------- ----------------------- Alterations and/or recommendations:-- ---------_------ ----------------- ----------------------------------------------•-----------------------------------•-------- ----------I---------------------------------------------- ------------------- ------------------------------------------------------------------------------- -------------- -------- ------------------- -- - --------------------- - ------------------------------------- -------------------------------------- ---------- -------------- --------------------- -------- ---------- ------------------------------------------------ --------------- ------------- FINAL INSPECTION BY:' - ----�-�- •- - - ----- Date ---- - - ---- -' - ---�-- -------- ----------------------------------- t - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxeltan Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CO-