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S F R QEi E USE: q� J � ------ 5 -- ------- d------ Permit No. .! C _ - �,_ � _; APPLICATION FOR' SANITATION PERMIT 1` (Complete in Duplicate) Date Issued . �. '•- ------------------ - ____ ________________ This Permit Expires 1 Year From Date Issue 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. _ ..'�z0100/ �� -------------------- _ Phone__ 21 Owner s Name------------------�-1�C__/-f',1---�----------------- -• --- Address--------------------------------- Z!9-3------ _... rlPfn --------------------•----------------------------------------------------------------•----------•--- Phone_' Contractor's Name + Gl Installation will serve: Residence ®/Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -_f--- Number of bedrooms __.Number of baths J____ Lot size -----------•------- Water Supply: Public system �Communi y system ❑ Private ❑ . Depth to Wafer Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [3,— Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date------------- ---_l No [3' New Construction: Yes [jNo [� FHA/VA: Yes E] No E3-- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 204 feet.) Septic Tank: Distance from nearest weii_________________Distance from foundation-------------------Material-----------_._.___.______-_______ -------------- ❑ No. of compartments--------------------------Size------•--------------------•---Liquid depth----------- - - ----------Capacity---------------- Disposal Field: Distance from nearest well. ------------Distance from foundation----------------_---Distance to nearest lot line____,___-`_____ �} ❑ Number of lines------------------------------- ---Length of each line-----------.------------------Width of trench......--------.--------------------- V' Type of filter material---------`----------------Depth of filter material-----------------------Total length_----------------------------------------� Seepage Pit: Distance to nearest well-__._-`�----------Distance fro/ foundafion____.7 ^__.Dista Distance to nearest lot line--. ------------ - ' --.- w �.3---- Depth •��— L� Number of pits.----....� g .C�ize: Diameter__ - . _____Linin matenal_,�' -�' 57 Cesspool: Distance from nearest well-----------------Distance from foundation.-- ------------- material--------------------------------- als. El Size: Capacity---------------------------- g Size: Diameter----- ------------- ----------- Depth_ ------ ------------ ----- ---------- ------ Privy: Distance from nearest well-------------------------------------------------Distance from nearest building.---------------------------------------- ❑ Distance to nearest lot line-- ------ ----------------------------------- �• Remodeling and/or repairing (describe}:--------- --�- � T� --------------------------------------------------------- ---------------------------------------•--------- ---------------- 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 s and regulations of the San Joaquin Local Health District. (Signed)----------------------------------- _.. -/x � - - ---------------- ------ ----- ( ner and/or Contractor) ------------------------ - Title _ By:---------------- - ---- - . -------------------------------------------- ( } [Plot plan, showing size of lot, location of ystem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- ----<�--- ------------ -- - ---- DATE `-- ---- ------------------ REVIEWED BY---- - ---- ------------ --------------- -------- --------•-- ---------- - ------------------------- -------- DATE---------- -------------------------------- ------------ BUILDINGPERMIT ISSUED---------------------------------- --------------------------—-------------------------------------- Alterations --------._Alterat' ns and/or reco m nda ions- - . <- - •---------------- ------ --_�'---------_----_-_-_-_------------------------------------------------------------------------------- -- --- --- f -----•---,L y---------- r . �-t r :4 �Y /1^s-�• ---------- FINAL INSPECTION BY:------- >_- -•------------------------------- ---- -- Date- �--/- /. - ------ ----�-- --�--------� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CO.