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-� FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. .. Z./ --------------------------------------- -------- ---- (Complete in Duplicate) y ------------------- ------- --- This Permit Ex ires 1 Year From Date Issued Date issued .-.. _____� 5 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 LOCATION = /Ga �7 CLF P Gc_ = '-._` -e-' -------------------------------------- -------- Owner's Name----C '-� �e_a="`'�"` ---•-•_( �` = -- -------------- ------------ Phone--------------------------------- Address----- ........... Ef ' .------------------------------------------------------------------------------------ Contractor's Name---)--)-7 C--- 0.to�- "=`' -------------------------------- ----------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _-f____ Number of bedrooms _--,. Number of baths __.(--_ Lot size ------ _____________________-----_- Water Supply: Public system JK Community system ❑ Private ❑ .Depth to Water Table ........ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 9 Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) 'No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well----- _____-------Distance from foundation_la----------- Material -_ t !/_._._:_-_____.__-----___. No. of compartments.---./-) --------- i_1�_��___ . .__Liquid depth_-__E _%------------Capacity---/ � " K. 11 �F Disposal Field: Distance from nearest weft-.___" "_-----Distance from foundation-----(0________.Distance to nearest lot line___&...'_-__.___- Number of lines-------:2 -----------------------Length of each line----! __—Y -------.Width of trench--------9-,.�----------.-.----•-- Type of filter material-__#& -----Depth of filter material----0q__---__.__ -Total length-_-._.7-------------___________- Seepage Pit: Distance to nearest well---—------------Distance from foundation_/D__ --------Distance to nearest lot line__4!�,.--_--____-_ � RNumber of pits-.--./-------.-----Lining material____.(O-Ck�..Size: Diameter_`-_'Y A_ZDeptn-- --f_ ----._-------S Cesspool: Distance from nearest well_---------------Distance from founda#.ion--------------------Lining material__---------------------.-.--_----_ Sizer Diameter--------------------- _---De th------------...---- -------------------------_Liquid Capacify----------------------------gals. Privy: Distance from nearest well---------------------------.--------.-------.----Distance from nearest building------------------------------------------ 0- 0 Distance to nearest lot line__________________________ A Remodeling and/or repairing (describe) ---------------•-------------------------------------------------•---------------•-------------------------------------- ------------ --------------------------------------------------- --------------------- ------------------- ---------------------------------------------------•------•-------•--•-----•------- ------ -••-------------------�) 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 Pad-,regulations-of the San Joaquin Local Health District. Si g ned . _ _ i �GLr- ------------ ------------------------------------------- Owner and/or Contractor By:------------------------- --------------------------------------------------------------------------------------------------------(Title)------------------- ....I.............. .. . ............... 1 (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPi KATION ACCEPTED BY-.T. ----=-�� ---------------------------------------------------•----------- ALF--------------------- BY--------------------------------------------------- ---------------------------- --------------------------------------------- DATE--�----------------------------- ------------------------- BrUILDING PERMIT ISSUED - - ---------- . DATE ."�------ �' v .---- .%- --- -;/ -= `-'------------------- Alterations and/or recommendations:._ ______.-___--__-_.__- ___________________________ -------------•------------------ ------------------------------------------------------------------------------------- ------------------------------------------------------------------------------=•------------------- ------------------------------------------------------------------------------------------------•--------------------------------------------------------------------•------•------------------------- ------------ ---------- -------------------------•--------•-------- ----------------------------------------------------------------------------------------•-------•-- ---------------- ----------------------------------- - --------- ---- - --------- ----- -- FINAL INSPECTION BY __ ------------------- Date.- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazsllon Ave, 300 West oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.C C.