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----- FQR fOFFICE USE: 5� .. l --------- ---- -----� T----- Permit No. .l� 1r ------- S- APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Date Issued - --------------------------------------------- ------------ This Permit Expires_1 Year From Date Issued 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 wit iounty Ordinance No. 549, t<77" ZED " F r'�f4:9 , 0-4 �+VLC � -, f JOB ADDRESS AND CATION___ �5s--------- ' � ��rt"---" }.- L - Owner's Name------- ---------- - -------------- Phone_----------w------------- ---•--- Address ------------------ ------ -------------- --•----••---------------------------•-----------------------•------ Contractor's Name-------- - --�� - Phone--------•-------------_---------- --- -- --------------------- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other C3 Number of living units: __/_ Number of bedrooms _A Number of baths __f__ Lot size _;/0..6--e/�.---/4� Water Supply: Public system Community system '❑ �Privete'❑ Depth to Wafee Table it. Character of soil to a depth of 3 feet: Sand ❑ Gravel 0 Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date--------------------I No New,Construction: Yes El,"'No ❑ PHA/VA: Yes �No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �' --__Distance from foundation__- ___ Mateal_.(� ,� '- ------ Septic Tank: Distance from nearest well______ ___ N � � ---- --- ®� No. of compartments.......R--------------Size_ ,C�__ - �- --Liquid depth---- -�a�---------Capacity--- ------ �( _f_--Distance to nearest lot line-�~�------ Disposal Field: Distance from nearest well._- Distance from foundajti�n__ __ .__. _ i �/ Number of lines_________ _____yr-.------ -. Length of each line___l �--- `-�----.Width of trench__-r_._____----.___------._ r� Type of filter material_��.��Depth of filter material_-_� ---------Total length___._____�-------------------------- Seepage Pit: Distance to nearest well---- --- _ ----------Distance from f ,undation__- nce to nearest lot ine__ ----Size: Diameter. -----.Deptl ---- ' Number of pits_-_._/--- --------Lining material_._ .�/ ---------- Cesspool: Distance from nearest well------- from foundation._----------------.Lining material------__-__---_...-__..__..____ Size: Diameter------------------------- - ------_"Depth--------------------------- ----------------Liquid Capacity--------------------- --gals- -______ ------------------ ----------Distance from nearest building.__._----..-__------._______ Privy: Distance from nearest well----- ❑ Distance to nearest ]of line.--------r-- `- Remodeling and/or repairing (describe):�- y - =-------------------------------------------------------- ---------------------------------- ------------------- ------------ ---------W -- ----•--------------------------------------- --------- ---------------------------------W--------- --------------------------------M-------------------------- ------------- -- -------- --------------- ------------------------------------- - --- --- ----------------------------------------------------------------------- ----------------------------------------------------------------- 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 and regulations of the San Joaquin Local Health District. ,� ------- -::•{_or Contractor) (Signed)----- ----- ----- - ---1 ---- --------------- - BY� -------- ----{Title}_ . -------- `-- /(Plot plan, showing size of lot, location of syste ' relation to wells, buildings, etc., can be placed on reverse side). ri FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- -------- ----------------------- ------------- -- ---- DATE------ �e4'---------..-.-.._----------- - \.,R'EVIEWED BY------------------------------------------------- -- -------------- ------------------------------ DATE. BUILDINGPERMIT ISSUED------------------- --------- ------------------------ -� -------------------------------------- DATE..----------------- ------ -------i------ Alterations and/or ------------------••--------•-- ------------------• -------------------- --- --- _- -- --- ----------------- ----------- --------------.- -- -------------------------- --------. -------------- -------------.- -------•-- . FINAL INSPECTION BY:------@� �-,.-Ewi -s------- ---- 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 t Manteca,.California �.- Tracy,California r.a.co.