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FOR OFFICE USE: - t_ (- ----------- Permit No. / --------------------------- -- S� _, APPLICATION-FOR SANITATION PERMIT CF�- �------ _ (Complete in Duplicate} _ az ----------------------------------------- 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 he ern deNcrifaed. This application is made in compliance with County Ordinance No. 549. ltica 2 JOB ADDRESS ATIQ\N__ ____- n_9--_ _ - -- --- ------------------ -------------------- Owner's Name------------- _C_7_ .2_--------_- ----------- •• -- `c ---------- - - ----------------------------- Phone-----------------------------•----- Address - --`� �---- --�-------- ---- ------- -----------------•---------- -�----•----- " '�' Phone-- Contractor's Name---- - - - ----- --•-•---- -�T_---- - � �----- ---- -- ------- --- _t_ --- -- •-- --- Installation will serve: Residence d tApartment House Commercia ❑ Trailer C rt ❑ Motel_❑ Other-� Number of living units.,-------- Number of bedrooms _ �� "------ Number of baths ________ Lot size ____- ----_- f / Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water TableCPp ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe f]'-FTardpan ❑ Previous Application Made: (If yes,date---------------------) No ❑ New Construction: Yes ❑ No FHA/VA: Yes ❑ No ❑ , . TYPE OF INSTALLATION AND SPECIFICATIONS: (�aD k or cesspool permi+tad if public sewer is available within 200 feet.) istance from nearest well_________________Distance from foundation_____---__________-.Material--_--------_______.______f________---_________No. of compartments------ -------------------Size--------------------------------Liquid depth-------=------------------Capacity---------------------- --- Ie Distance from nearest well.P(0_f1et .Distance from foundation__�✓�_�__-Distance to nearest lot line-_-_�"�'___� d4-1 Number of lines_________ ______ Length of each .line_ —. - _ `fWidth of trench`__,. k_ ��.____.__�______ Type of filter material_ ¢1 --Depth of filter material--- -Total length_:%____..___.-__ _�_______� r e �i#� Distance to nearest well.--�'�____�s__Distance from foundation___ ___ __._..___.Distance td nearest lot line__-__._________ Number of pits_--��---------------Lining material__RQ. --_--Size: Diameter__--- Depth____Qez__------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--------------------------_-----_____. ❑ 5ize: Diameter - Depth . -------------------------------------------Liquid Capacity---------------------------gals. -Privy: Distance from nearest well__________________ ________________________ _Distance from nearest building---------------------------------.--_ ❑ Distance to nearest lot line-----------------------------------------------••---------------------- ----------•---------------------------------•--------------------- Remodelingand/or repairing (descr&):--------- ----------------------- ---- ----------------------------------•--•-------------------------------------------------••--------------------_--- .1 } hereby certify that I have prepared this application and hat the work will be done-i accordance with San Joaquin County ordinances, St a�s, a rules and regulations of the Sa oaquin Loc eaith Distric . (Signed} �. ---- --- --- ' �Contractor) By:----------------------- •- -- -------------------------------- ------ - - (Title}_ (Plot plan, showing size of.lot, location.of system,in rela n to wells, buildin s, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------- DATE a' Q �� ------------------------- REVIEWEDBY-------------------------------------------- ------ DATE---------------------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------ -------------------------------.----=--=------------------- DATE------------------------------ ------------------------------ Alterationsand/or ecommendati :-- --------------------------------------------------•- ---------------••----••--------------------•------------ -----------_----------- --------------------.-----� � ,�----- 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 ES 9 REVISED a_S9 3M 3-163 F.F.CQ. I