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FOR OFFICE USE: - - ----------------- ------------------------------- -------------------------------- ------------------------ APPLICATION FOR SANITATION PERMIT Permit No. --------- ------------------- -------------------------- (Complete in Duplicate) --------- 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 herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND�LjOCA�TjION ----fa---��---� � � �f xt Owner's Name------ 6 �y •-•------- ------- --- - ........ Phone----- -------------------------- Address_____.. _ ----l./ 1 -� -�: J ,�------- Contractor's Name----- t'�� /--------------------------- Installation will serve: Residence [Apartment House E] Commercial E] Trailer Court F] Motel [_1Other E]Number of living units: _f-- Number of bedrooms of--- Number of baths .a __ Lot sizegy' _______________________________ Water Supply: Public system ❑ Community system ❑ Private `Depth to Water Table4�t Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam E] Clay Loam E] Clay ❑ Adobe B'Hardpan ❑ Previous Application Made: (If yes,date--------------------) No R` New Construction. Yes [�f---No ❑ FHA/VA: Yes [�r No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted.4 public wer is available within 200 feet.) Septic Tank: Distance from nearest well ___�v_ --_ Distance from foundation__/4------Material /' --------------- a -------------- / No. of compartments----- -----------------Size-44 _--- i1�, Liquid dep�h-- - -- apacity`,24idt' -----/ pisposal Field; Distance from nearest well__cfp_-_...Distance from foundation_A-�_-__ i Distance to nearest lot Number of lines----�-------__ g ,f �j I I - - Length of each line_ -_,tel? _______-___Width of trench.rt'_Sr______________________r.__:_ Type of filter material/ Depth of filter material__% � ' Tota! length -lfll -= `*,�- Seepage Pit: Distance to nearest well_. ,`-7 -------Distance from foundation___2Q�__-_-.Distance to nearest lot line__,: -_j f Number of pits_.'____--------------Lining material___,/I�k!:��5ize: Diameter .,3,� Depthv.��-r� °-----------.- Cesspool: Distance from nearest weft-----------------Distance from foundation.-------------------Lining material_.--------------------- -------------. ❑ Size: Diameter--------------------- -----------Depth----- --------------- - ---------- ------ - --Liquid Capacity-------- -----------�-----gals. I Privy: Distance from nearest well_ ____________________________Distance from nearesf building lv� ❑ Distance to nearest lot line - - ----------- `1ti Remodeling and/or repairing (describe):---------- �P,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 laws, and rules and regulations of the San Joaquin Local Health District. (�Contractor, (Signed) 1---�� ---- Y ---------------------------------- •--------------- - -------- ----------------------- Titl p-- n (Plot plan, showing size of lot, location of syst in relation to wells, buildin s, etc., can be laced on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTEDBY-- - -- ----�,.. -- ---_._ DATE---- -- - �47r_ -- - ------------------------------------- -- REVIEWED BY------------------------------------------- - --------------------- ------------------------------- DATE BUILDING PERMIT' ISSUED------------------ - DATE.._. -------------------------------------------------------------------------------- Alterations and/or recommendations:____-_._ . -----------------------------------•--------------------------- -------------------- ------------ ---------------------------------------- --------•------------------------------ ------------------------------------ ----- ---- -------- ------- ------------------------------- ----------------- ------------------------------ ----------- ------------------------- i FINAL INSPECTION BY:-; `! Date_ f_`t_0//.7 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Naselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 4th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.C❑.