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FOR OFFICE USE: 7 7- -------------------- ------------- ----- - S APPLICATION FOR SANITATION PERMIT Permit No. ....................... -------- �. -- � (Complete in Duplicate) a S ----- -------------- - Date Issued �_Y�.------------- ----------------------------- . -__ Permit Expires 1 Year From Date Issued - T#lis__..._.. 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 N 5411 e�'-- F JOB ADDRESS AND LOCATI*O�N-- - - -- - ------Q -'----•---....------------------------------•-----•--------------------------•-------- 1, Owner's Name..------ -- ------------------ ---- --- ------------•-------------------- ----- ---.-. Phone.----------------------_--------- Address-------------------------- � .�.-_. �4�1�'--.... � • Contractor's Name-------------- ��- •-------------------------- ----------------------••----------------------------•--- Phone....---••---•--•----••--•------.... Installa+ion will serve: Residence U?Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ._- Number of bedrooms.--_- Number of baths -p-_ Lot size--- -- -._ - -' _ Water Supply: Public system ❑ Community system ��rivate ❑ Depth to Water Table - ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam,❑ Clay Loam ❑ Clay ❑ Adobe�ardpan ❑ Previous Application Made: (If yes,date--------------------) No Ul/ New Construction: Yes I?,Ao ❑ FHA/VA: Yes ®/No ❑ j TYPE OF INSTALLATION AND SPECIFICATIONS: j (No septic tank or cesspool permitted if'public sewer is available within 200 feet.) Septic Tank: Distance from nearest well -$�.-._-Distanf�e from fo 1, ation.__l�✓--------- Material-- - l"'l --------------------- No. of compartments....�----------..... Size-"--_.W_40eWiquid depth---!�-f------------------Capacity__,,_1�9199:2-_ i �i Disposal Field: Distance from nearest well--e�---..-Distance from €oundation. - .-......Distance to nearest lot line--- ------------ 41 Number of lines------- Length of each line-,7j -------Width of trench-- - ------------------------•-- Type of filter material/I. 147-4/6Depth of filter material__f P--------.-Total length-----/J27------------------------ Seepage Pit: Distance to nearest well-/-,x_14-1----Distance from foundation...) ........... to nearest lot line-.6----------- p' -------------Lin!n%4 material-- QG1 _-Size: Diameter--- ...- Number of pits � - - ►��a.----..Depth--P�_t��----------------• �+ Cesspool: Distance from nearest well----------------Distance from foundation--------------------Lining material------------..--.--_-__-----_---- ❑ Size: Diameter--------------------------------------Depth----------------------------- ----------------------Liquid Capacity--------•---•--•------------gals. Privy: Distance from nearest well------------------------------------5------------Distance from nearest building------------------------------------------ ClDistance to nearest lot line- ------------------------------------=---------------------------------------------------------------------------------------------------- 00 Remodeling and/or repairing (describer--------- - -90_4 -----------------=------------••------------------------------- -----------------------------------------------•-----------•-•-------------------------------------•--------------------------...--•--------------------------------------•-•-----------------------------------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 +he San Joaquin Local Health District, (Signed) ids ------------------------------ �YSRi Contractor)� F ----- ------- --------------BY: (Plot plan, showing size of lot, location of sys+ in relation to wells, buildings, etc., can be placed on reverse side). f FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED'BY------0---*-----cFzxx'�`� --------- -----------•---•--•-------- ------------------- DATE------ 5 - b I------------------------- REVIEWEDBY---------------`--------------------------- --------------------------------------------•-----------------•---------------- DATE----------------.-...------------------------------- SUI LDI NG PERMIT ISSUED-------------------------------------------------------- ---- ----------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:-----------------------------------------------------------------------------------------------------------------...---------------------------------------- ------------------------------------------------------------------_--------------------------------- ----------------•-•---------------- ------------------•-••-•------------------------------------------------------ -- ------------------------------ ------ ----------•--------------------..------------------------------1------------------------------------- - ----- --.. . -- . t FINALINSPECTION. .BY:.--------C....... ---------=•---------------- Date--------q------ 4-------------------------------------... SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124-Sycamore Street 205 West 9th Street Stocktonr California Lodi,California Manteca,Californiaa Tracy,California F.9-9 REVIBEO 0.59 F.P.00.ZM 6.60