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FOROFFICE USE: -�- --_ ------------ ------------------------ ------------- APPLICATION FOR SANITATION PERMIT Permit No. ._L _1..9o�s`� + ------------- --- -------------------------------------- (Complete in Duplicate) - --- This Permit-Expires 1 Year From Date Issued Date Issued __ - � r Application is hereby made to the Son 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. r. JOB ADDRESS AND LO>AjJO ?au�_ P1 �- X24 �,� Owner's Name -- __l -' ------ Phone..----------•--------------•-•------ Address------------- � - 1 ._ -- -- --------------------------------------------- Contractor's -- - • -- Contractor's Name --------------- - Phone -- Installation will serve: Residence Apa tment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. Number of bedrooms _Number ' baths _?- Lot size ____ ----------------------------- Water Supply: Public system ❑ Community system ❑ Private Depth {o Water Table ___-._._ ft. Character of soil to a depth of 3 feet: Sand [❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay Adobe❑ Hardpan ❑ Previous Application Made: (If yes,Idot e---_------- --------) No. New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ t TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank*or-cesspool-permi++ed if-public sewer4s available_wi+hin:200jee+.) Septic Tank: Distance from nearest well-________________Distance from foundation--------------------Material -._________-_-.____-._ __- ❑ No. of compartments-------------------------_ Size------------------- ------------Liquid depth------------- -- ---------Capacity------- Disposa field: Distance from nearest well---- Distance from foundation-------l__4_`__.Distance to nearest lot Number of lines-1-----------I Len_gfh_of.,each line--------------4'_`---------.Width of 1 _ t t rench.__- rro _-___ �4TYpe of filter maSf filter material_ g__- _Total length------- ___-__,_f___ __________ ---�-------- eeit: Distance to nearest well-----1_a_0---------Disfanee from foundation-----/4___ _Distance to nearest lot line.- S_-___------_pNumber of pits--- 7--__---__Lininmateria ____.-Sie: Diameter - .---Depth_____. _ -_r---------- Cesspool: -•-_- Distance from nearest well________________Distance from foundation----------------.__.Lining material_-.-__ __-_-___. F-1 Size. Diameter --------- ------- Depth ----- -----------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-___-_____-____________________________________Distance from nearest building.____.-____._______.___________________. ❑ Distance to nearest lot line ---•---------------- ----------------------- ------------------•----- Remodeling and/or repairing (describe)_------------------------------------------------------------- ----- ---------------------- --------------------------------------------------------------I-----------------------------------------------•--------------------------------- -- ------------------- ---------- ------------- -----------------------------------------------II------------------------------------------------------------------------------------------------------------------------ -------------- ---------------------------------------------I----------------------•------------•-------•--------------------------------- -------------------------------------------------------- --- ---- ` - - ! hereby certify that I have prepared +his application and {hat the work will be done in accordance with San Joaquin County ordinances, State laws, d rules and regulations of the San Joaquin Local Health District. Q (Signed)---------------------- _ _ s _ _ � --- - ------- ------------------- -------- ------- -- ---------- -- and/or Contractor) r By:----------------- ---- --- -- - - a o (Plot plan, showing size of lot, location of system in r tion to wells, buildings, etc., can be placed on reverse side). r FOR DEPARTMENT USE ONLY + APPLICATION ACCEPTED BY-. ------ --- ----------------------------------- DAT ---- z- ---- 6 ----------------------------- -------------------------- REVIEWED BY - -- ---------------------- ------------------------------------------------------------------------------------------ DATE k BUILDING PERMIT ISSUED --- ------------------------ ------------------------------------- . DATE--------- -----------# Alterations and/or recommendations:______________________ ---- ------------------------- r =------- ------ -- ------------------- ---------------•---------------------------•--- -------------------•--------•--------------------------`------------ ------------------------------------------------------- I 1 r FINAL INSPECTION BY:_�!i � F Date '� I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th street Stockton,California Lodi,California Manteca,California Tracy,California