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r1_JK vrric_r uac: -------------------------------------------------- ------------------------------------------------------ APPLICATION FOR SANITATION PERMIT Permit No. ... ...... ..... ---------------- -------------------------------------- (Complete in Duplicate) / Date Issued -------------------------------- This Permit Expires 1 Year From Date 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 compliance with County Ordinance No. 549. '] JOB ADDRESS AND CATIONvyF - ��1C-r .�'1i..�r_t-- -,�_ll....___� � - h'� .1.G{{... Owner's Name - ----- -- ----- ------------.._..----_. Phone Address------- .... Contractor's Name..._.. _-.------•--•-----••--------••----.•-.--------- . .----•--•-•----------------------------•-•- Phone................................... Installation will serve: Residence Apartment House ❑ Commercial )d Trailer Court ❑ Motel [I Other [I Number of living units: -1..... Number of bedrooms ----L. Number of bathh�___...�L t size ��-�_.�!'................................. ` Water Supply: Public system E] Community system I-] PrivateX ;ep;ito a r ab _46ft. ►. Character of soil to a depth of 3 feet: Sand ❑ Gravel' Sandy Loam [A Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (if yes,date--------------------1 No,K New Construction: Yes ❑ No FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if p blit sew is available within 2 I Septic Tank: Distance from nearest well_��_# stanc from foundation._!-,�' er-ai............. :............ No. of compartments Liquid g C_- _--Liquid depth-----__--- - -------Ca aci .6_0.......... Size P ty ttF Disposal Field: Distance from nearest well-----------------Distance from foundation....................Distance to nearest lot line................. �- ❑- Number of lines_.......4---------------------------Length of each line-___----__------._.-__--.__.Width of trench----_----_--_----------------- 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--------------------Lining material__-.---_-_--_-----.----__------.-_. ❑ Size: Diameter-------------------------------------Depth----•---------- -------------------------------------Liquid Capacity-----------------------_-•-gals. Privy: Distance from nearest well_________________________________________ ___ Distance from nearest building------------------------------------------ . ❑ Distance to nearest lot line------ ----------------------------•----------------------.-.---- — Remo ling and/,or repairing �descri,be) a.__dpi/`- - -- -- ---- -- ___-fi!L� ?J 1___ .lt._t .t+Q_.s _.F c„j:...__ _.--"'y*-�.<___ '-•x" �;,->�r-.gl�y--_-'`'rS'r- .-- _'t'-`c;4.:.�--_-•__-------_-- _ ---- _. v ------------------------------------------------- I hero 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 the San Joaquin Local Health District. (Signed) ='E t --------- -------------------------------------------------------------------- -------.(Owner and/or Contractor) By:.......... - 4�� ., & ---------------_-------------------------(rifle)----Y -- ----------------------- (Plot plan, showing size of lot, location of system in re io to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- •-------------------------------------------------------------------• ------------------•---- DATE.. -REVIEWED BY BY--•----------------•----•----•--------------- s----------------.--------------------------- DATE- ' BUILDING PERMIT ISSUED----------------------------------------------------------- -------------- DATE------�-�-----t�` Y Alterations and/or recommendations;---------------------------------------------------------------------------------------------........ ------------- ••---------•-------- ---------• ------------------------------------- ----------- - ------•---------------------------------•--•-••---------------------------------- FINAL INSPECTION BY------- ------------ ------ -------- Date--------/_4 -./7.- • SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8.59 RM 5-81 ArLAS