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FOR OFFI� E: S 1 - - - -6-�-=---- --- - Permit No. ----••--------••-•------ = :x, APPLICATION FOR SANITATION PERMIT I---- (Complete in Duplicate) Z—� 1 -----____-------- --- 'This Permit Expires 1 Year From Date"Issued Date Issued _ ___ ._'.............. Application is hereby madelto 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. h -.-/--'----,GJX-----'""'-l`-''---- --'-------fes•-• -•`-------------------------�-'---~-----• JOB neADNamse- AND LO --------------- -------------- ice-' Address-------- -----------i ,- = .C -� �' a - - Contractor's Name._.--_--____•_ I " # - - ,. •-- --------- Phone Installation will serve: Residence ff .Apartment House❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ , ! Number of living units: Y.A. Number of bedrooms _' _ Number of baths ...,f_ Lot size _-_-...,; - f-__- �" r Water Supply: Public Syste� ❑ Community system ❑ Private [`"Depth to Water Table .?�a�ift. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam X' Clay Loam ❑ Clay ❑ Adobe[3 Hardpan ❑ Previous Application Madel' (If yes,date--------------------) No New Construction: Yes E] No FHA/VA: Yes'❑ No KI TYPE OF INSTALLATION SAND SPECIFICATIONS: (No septic tank or.cesspool permitted.if public sewer is available within 200 feet.) Septic Tank: Distance from,nearest well-_ .f'o----Dist�Distance -nXce from-f-�ou'nd•a_t_ion__:.: } Il. _---.Ma ------------- Disposal terial--� Capacity_�Noof"compartments :------Size Liquid depth------- Dis asal Field: Distance - from nearest well-.-��__---.Distance from foundation to nearest-lot line-----/-- �( Number of lines--------_--•-- ------------------Length of each'line---------- — _Width.-of'trench----_---•_-----�--•----•-- Type of#filter rriatenal -_---Depth of filter materi ---_._� _-.Total length------------- al .( - t ---------- Seepage Pit: Distance to nearestwell----------------------Distance from foundation--------------------Distance to nearest lot line----------------- ❑ Numbe'r�'of.pits------ €--------------Lining material--------•--------------Size: Diameter------------------------Depth----------------------- ------ IMS t Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--_---------------.---- ___------ ❑ Size: Diameter--------------------------------------Depth------------- ---------------------------------Liquid Capacity--=---------•- -------gals. Privy: Distends from nearest well----- -'- `*'t ----------- -------------Distance fromnearestbuilding------------ - ---_--------------- Distance _--------_ ❑ Distance to nearest lot cine_--~----------------------- 1 Remodeling and/Ir repairing (describe)--- ----------- -- - 4�- .`�'�---•-- ' �'---------------`. < ---------- dt - ------------- --------------- -_---_-_--.:- -- h4- 6------__4__-- _--._-------_--...._-_-----__-_:.-___.__---___.______-_-.---_------_--_-_---___-...--__----_-_-- € J � -----------------•------------ ----------------------------- -------------- i ---------•-------------....------ �.:---------- ---------- ------------------------------------- - i . I hereby certify that 0have. prepared this'application and'that the"work will be-done in accordance with San-Joaquin County ordinances, State laws, and rules and reguI tions_of the'San Joaquin Local Health District. (Signed)------------- � ---` --,--- ---- ------ ------------I---------------------------------- ----- t (Own and/or Contractor s r By:__------------- = (Title} (Plot plan, showing size of+lot, location of system inJrelation to wells, buildings, etc., can,be placed on reverse side). - - DEPARTMENT USE ONLY DATE- ;x-- �' ------------------ APPLICATION ACCEPTED BY----------- I --------- = REVIEWEDBY---------------------------------•--------------------------------- --------------- ------------- DATE =- BUILDINGPERMIT ISSUE ---------------------------------------------------------------------------4----------------------• DATE-------------_--------------- ------------- ------------ rl _ ---".". - Altera on and/o recommends ns:-•----.-4-- --_--- -• - ! _ t -- ----------------------------'- R ----_ ---"- II�� -- -• ---------- ------• _----_----. Jf ] .I� ` -.------I-----------------•-------------------------------- --------------- -- •-----------------------------•--......---_-----_. _ - FINAL INSPECTION BY--------- ------- --- - (i( — Date---- " L! -- li SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E6.9 REVi9E9 0.59 F.P.CO.7M 6.60 r