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FOR OFFICE SE: ------------------- ---- - APPLICATION FOR SANITATION PERMIT Permit No. _..._. -.'::._... r-------------------------- ---- -------- (Complete in Duplicate) / -. This Permit Ex ires 1 Year From Date Issued 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 with my Ordinance No. 549. JOB ADDRESS AND LOCATI N--•------J------- _.... .. Owner's Name. t. Phoi i R..77/7u I -------------------------------------------- Address---------------------- ---- --------------------------------------------------------------•------•-----------•-----------------------•---------------•••-----------•--------------- Contractor's Name............ ---- -----------------------••------••---.------ ---_------------------- Phone----------------------------------- Installation will serve: Residence Z Apartment House ❑ Commercial ❑ Trailer Court ❑ MMot9l ❑ gOther (INumber of living units: j.__. Number of bedrooms _9L Number of baths /.-'. Lot size .___../..-Q--! -- -C_ ------------------------- Water Supply: Public system ❑ Community system ❑ Private A Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan [] Previous Application Made: (If yes,date___-----------------) NoA New Construction: Yes No-E] FHA/VA: Yes ❑ Noa 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.--------Distancg frony foun)a+ion__110-_-_-_...__.Material____ _________ -------f-_It-..-- .___-.,No. of compartments________ �� Ca as ------------Size.�.�______X_•�---._-_Li Liquid de +h__...- - Disposal Field: Distance from nearest well--- .. Distance from foundation__ __,0 j.._.....Distance'to nearest lot line................. Number of lines___________,___ ____.y__�_ _ ength of each line--------zf-0-- Width of trench_.____ _ __ ,Type of filter material _. -.- _- �L_+�I epth of filter mbterial___�49............Total length-----__1_ ___!�_.______________.__._ Seepage Pit: Distance to nearest well----------------------Distance from foundation----------.---------Distance.to nearest lot line--_--______-___._ V ❑ Number of pits__'-'----------------Lining material....-,.--=------------Si'z'e: Diameter-----------------------Depth------- .---•----------- r Cesspool: Distance from nearest well__ _____________Distance from foundation--------------------Lining material.-__..______-----._..___-.._._..___._ ❑ Size: Diameter--------------------------------------Depth---- ------f----------------- ----------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well._.___________________________________ __Distance from nearest building_____.___.___________________._____---.-. ❑ Distance to•nearest lot line-7-------------------------------------- --------------------------------•-----•------•---•---------------------------------------- l i 1 Remodelingand/or repairing (describe):----------------------------------------------------------------------.................-----------........•..............----------------•---------------- ------------•----•----•-----------------------------•;-------•-------------------------------------------•---------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------•--------------------------------------------------------------------------------- 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 andiregulations of the San Joaquin Local Health District. (Signed) ----------- (Owner and/or Contractorl i By:------------------- ........------------------:-------------- - ------------------------------------------ - -------------(Title)------------------------------------------------- -------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED � _____ ----------------------------- ______ ____ REVIEWEDBY----------------------------------------- -- -------------------- -----------------------------------------------------__ DATE-----------------------------------------........----------- BUILDINGPERMIT ISSUED------••------------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations--------------- ------- ----------------------------------------------------------------..------------------------------...._.....------------------------- --- -- ----- -- ---- _ J— ------------------------------------------•------------------••---- ------------------------------------------------------------- ----------------------------------- ------- ------------------------------------------------------------------------.------------------------------- ------------------------------------------------------------------------ c~ FINAL INSPECTION BY:.... Date------ --------------•----------------------•--- h 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 ES-9 IPEv ISE 13-59 F.P=.2M 6.60 v�