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fDOROFFICE USE: ------- /- --------- ---- -- ------- .__.. APPLICATION FOItSANITATION PERMIT Permit No./,F,:�....__.. --- ----I--------------------------- -------------------- (Complete in Duplicate) ,p ------- - - ----------------- ------ ------------ This Permit Expires 1 Year From bate Issued e \ N,Afedssued l--=__�--_- -5Application is hereby made to the San Joaquin Local Health District for a permit to const'u�t'an i he work herein described. This application is made in compliance with County Ordinance No. 549. 4 JOB ADDRESS AND LOCATION------------------------- ---------------- ' ------------- Owner's Name------------------------ ------0- -- --------------------------- ----------- ------------ Phone------------------------------------ Addresslr� - /r�!/e%6 ----------------------- ----------------------------------- ------------------------------- Contractor's Name - ---------------------------------- --------- Phone.."�y"o(,b._'---------------- Installation -------- ----Installation will serve: Residence ❑Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -_-Number of bedrooms __ 7��Lumber of baths -- Lot size __10 -/ __---______________________ i Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand E❑ Gravel ❑ Sandy Loam ❑ Clay Loam [c�Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made:_(If yes,date............. r } •No ❑ _ ,New Con struct.ion:_,Yes,,.❑—No•El.,.-FHA/VA: Yes ❑ No ❑ i 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-------------------Material------------------ _____._________-___-______- ❑ No. of compart' - Size-_encs-_ ----------------------5ize- -=------------------------Liquid depth-------------- - --------Capacity_-.-------------------- W 1 01 Disposa Field: Distance from nearest wellDistance from foundation- 4)__________-Distance to nearest lot Number of lines-------f----------- ------------Length of each line----�2,5_.............-Width of trench----- W --'--____---------- Type of filter material___- Depth of filter material--- -------_Total length-----Z!5_----------------------- Seepa Pit: Distance to nearest well----------------- -_-Distance ft m foundation__�S.......Distance to nearest lot line____-- ..._ f• � Number of pits...... ------------Lining material_ ._5ize: Dia meter_'. __...____-- Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining materiai------------------------- ------------- F-1 Size: Diameter----I---------------------------------Depth-------------------------------------- - ------Liquid Capacity-- ----------- ---------gals. i Privy: Distance from nearest-well----- ----------------------------------_ ------Distance from nearest building-----.-;_______._-__-_-----------_----. 1 ❑ Distance to nearest lot line_______________________ _ __ 1! - t Remodeling and/or repairing (describe):---------- ______.__/-D_-- /� --------------•--•--------------- ------------------------------1 --------------------------------- ----------------- -- ------------------------------------------------------- --_----------=------------- _ _ ------------------------ •-----------------------------------------------•---•------------------------------------ ------------------------------------------------- It I hereby certify that I have prepared this application,.and=+hat.the..work.will�be.done in accordance with San Joaquin County ordinances, State laws, and and,-regulations-o, e San Joaquin-Local•Health District. s (Signed) , _ /--�1 ----------------------------------------------------------- �( Fgr /or Contractor) a ! By: - ------ -- -- -------------------------------•-----------[Ti+lel (Plot plan, showing size of lot, location of syst m in rela+ion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__4'-_ r- Y DATE-- .. ��1: _ -- - -- ----------------------------- REVIEWEDBY ----- -------------------- ------------- ------------------------------------------ DATE------------------ BUILDING PERMIT ISSUED-------------------------- ------------------------------------ ------ DATE - Alterations and/or recommendations:----rr-141.6�'----,Xi - ------------------------------------------------------------------- ------------------------------------- - ----------------------------------- I -----"--------------I•------ .-----------------_-.__..-----------.----------.----- � FINAL INSPECTION BY:. ----------- - •- - ------------ Date...._5 ;--/& 65 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 Tracyr California -r 7