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0 FOR OFFICE USE: J � T APPLICATION FOR SANITATION PERMIT Permit No. --------------------------------------------------------- ------------------- - ----------------------------- (Complete in Duplicate) Date Issued Permit 1 Year From Date Issued A lication is herebymade to the SaIh Joaquin Local Health District for a permit to construct and install the work herein described. ' This application is mde in compliance with County Ordinance No. 549. JOB ADDRESS A LOCATION--r.4 0 -- � _,,�y Owner's Name --- - 41.71 � -------- -------------- Phone-------------------------•-----•---- Address___ .. __ -•----------- - Name---------- ' Phone----------------------------------- Contractor's Installation will serve: Residence [;Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ __ Number of bedrooms -Y.- Number of baths z Lot size /" `------------------ Water Supply: Public system ill,"C' ommunity system F1Private F1Depth to Water Table / ft. Character of soil to-a-de0'fh-c f 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0--*Hardpan ❑ rt Previous Application Made: (If yes,.date--------------------1 No New Cbnstruetion: Yes [&-No ❑ FHA/VA: Yes � No F-1� :t TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) s Septic Tank: Distance from nearest well----�------Distance from .oundation---/_�-__----.Mat isl- P"�_r �' -1----- ----------- �' No. of compartments--- ------------------Size-,YX_,7- X.J.Liquid depth-- Capacity" .___ o --� --- --Distance to nearest lot line_ L -___-- Disposal Field: Distance from nearest well___.-'- _'_---.-Distance from foundation-,/ -�. Number of lines__.-------- ------------_Length of each linep� --------Width of trench- -"-"-___ r� ------------------ Type of filter materiallj7�(CDepth of filter material_-�re_------_---.Total length-- , ----------------------- Seepage Pit: Distance to nearest well-_---------___---- Distance from foundation--------------------Distance to nearest lot line-------------------- El Number of pits---------------".- ---Lining material-----------------------Size: Diameter----------------------Depth------------------------_----- - Cesspool: Distance from nearest well------------- Distance from foundation.-------------------Lining material_.-----_------------__.---------"--. ❑ Size: Diameter- `---------- --------- -----Depth----------------------------------------------------Liquid Capacity- --------------------------gals. I ----Distance from nearest buildin Privy: Distance from nearest well 9 - --- ---- -- Distance to nearest lot line------ -------------------- --------- --•--------- -----------�-----�" �--�-------------------------------------- -------- ---- } v -------------------------------- i Remodeling and/or repairing (describe]:--____._:."/[mss(-- ' ---•---------•---------•-------------------------------------=------------- --------------------- - I ---------------------------------------------------------------------------=------------------------------------------------------------------------------------------------------------------------- --------------------- -------------------------------- -------------------- -------------------- ---- - -- - -- ---- ---------------------------------------------------------------------------------------------------------- ------------------------------------------------- ------- ------ IT hereby certify that I have prepared this application and that the work will-be done in accordance with San Joaquin County I ordinances, State laws, and rules and regulations of:the San Joaquin Local Health District. (Signed) -- ------------------------------------- ------ {Vr Contractor} ------------- - - tion of system to ration' (Title)------ _ :-_-------------------------- ---- 1 BY� ------ -- (Plot plan, showing siie of lot, loco y to wells, buildings, etc., can be placed-on reverse side). ,r 1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .... = - ------------------------ DATE----AOS- fJ ------- ------------------ REVIEWED BY--- --t------------- - - ------------ - - ---- - -------------- --------------------------------------------- DATE------------------------------------------------------------ - -------- BUILDING PERMIT,15SUED---------------------------------- ----------- DATE-------------------------------------------------------- c Alterations and/or recommendations--------------- --- ------••----•-•-••---•-------•---------------------------------------------- ------------------------- ----------------------------------------------------------------------- ------•----------------- --------------------------- ----------- ---------------- --------- - ---------------------- --------------------- ------- -----------" ------- --------- ------- ----• -----•-------- --------------------------------------------------------------- /� / ------------------ ---- ------------ FINAL INSPECTION BY:------ -�1 - Date---_-.-7 `'_-----( - - t SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Hoxelton Ave. 300 West Oak Street s 124 Sycamore Street 205 West 9th Street-- Stockton,CQllfarMO Lodi,California Manteca,California Tracy,California F,P.CP.