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FOR OFFICE USE: {� ------------- No. �- •- ----- -----I------ APPLICATION FOR SANITATION PERMIT Permit(Complete in Duplicate] --------- ------------------------------------ ------- Date Issued 1� G _ _---- ` This Permit Expires 1 Year From Date Issued Application is hereby made to the Sant 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. Q/1 L,Q .------•---------------------------------- ------- JOB ADDRESS AND LOCATION..___S--3 ------- A4. ---------•°'- __ ._.____ __ T ---------------------------- --------- Phone--- . -.�a!-gf3-- Owner's Name.-----�-�---"-•--- • -- ---------- -- - --- t Address" ----- Contractor's Name------- --- ----------------------- Phone---t�--�G_M' Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ CP i Number of living units: "�-_ FNumber of bedrooms _-�_. Number of baths ..-l_ Lot size ----".----.1a_"-""""_-.----.------------ L Water Supply: Public system ❑ Community system El Private []Depth to Water.Table ."a_ ft. Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam ❑ `Clay Loam ❑. Clay ❑ Adobe Ee Hardpan ❑ Previous Application Made: (if yes,date-----------------"-.f No ❑ New Construction: Yes ❑ No [L4-*1 FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet,] ep is Tank: Distance from nearest well-----------------Distance from foundation--------------------Material------------------------------------------------- No. -"-".."---."""._.__"...........................No. of compartments---- --- Liquid depth------------- --------Capacity - - -- ---------Size--------- ------------------•-- � ----------------------- Disposal ---- --------------- . _D"---_".Distance to nearest lot IineS____ Disposal Field: Distance from nearest well... Distance from foundation._-"�_ Number of lines----- Length of each line.______`._6--4 - of trench .._a _y__i [� Type of.filter material_S+_� Depth of filter matenal.__-".��"""---.---Total length______________S�________!________ _l Yp / Seepage Pit: Distance to nearest well..-/Q _'__._--Distance f om fpundation___7�Q_-_____._.Distance to nearest lot Iine:_+g_.._ .___ Nbg� umber of pits------ materiae---Size: Diameter- ca ._,�_ -._.Depth.......a_5----------------- Cesspool: Distance from nearest well-----------------Distance from-foundation_.-.-.-_--:----._._Lining material-_".._.__.--___ ".___.---______als. ❑ Size: Diameter- Liquid Capacity---------------------------- k - Depth = g Priv Distance from nearest well-------------------------------- ------------- -Distance from nearest building.......--------------------------------- y:. r ❑ Distance to nearest lot line-------------------- ----- -------------------------------------------- ----------------------------------------- -----------• _ Remodeling and/or repairing (describe)----------------------------------------------------------------------- r i --------------------------------------- ---------------------------- -------------•--------------------------------------------------------------- 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. Contractor] (Signed] -------- f►P/i� --------- �Or end/or BY= .- "-----------------------------------------(Title) (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be pla ed on reverse side]. i FOR D PARTMENT USE ONLY APPLICATION ACCEPTED BY----- _ ----------- ------- ---------- --------- ------ DATE------ ------------------------- DATE---------------------------------------- i -------------------- REVIEWEDBY------------------------------- ---- -- ---- ----------- ------------------- I BUILDING PERMIT ISSUED-- -----------�- --------------- ---- ------- ---- -- ------- ---- - DATE------ -------------------------- ------- �� - Alterations and/or recommendations:-------/� (1�----= --- --`- - - :- --- ---------------- ---- - --- --_ ---------- ----------- ----------..------------------------ ------------ ------- ---- --- ----------------- ------------- 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.