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FOR OFFICE USE: . ._- ` ------------------------------------------------------- -_"- ---"-_ _.---"" -_--____-""---_"----------------- APPLICATION FOR SANITATION PERMIT Permit No. _._21 .. !••• ----------------------------- --------------------------- (Complete in Duplicate) Date issued .. Z_1__..----------____.__.__ _._.._____------------- 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 insta a work herein escribed. This application is made in compliance wit unfy Ordinance No. 549. JOS ADDRESS AND LOCA�'TION �l I �� Phone.Owner's Name---------- - -----------'J -------------- ---- - _---- ------------------------•----• Address--- - -- ----- - -- --- ---------------•---------- ----- ---------•--- ......--- ------.......----•---•---•--------•---------•----------•-- •-----•-•_.. Contractor's Name---------......... •- - ------ •-••------•---------•----------------•-----------------•---------- ................................ - Phone....................----.....•--•-• Installation will serve: Residence artment House ❑ Commercial ❑ Trailer Court ❑ Motel [3 Other Number of living units: ___1... Number of bedrooms J_ Number of baths ___ Lot size _.._J___ Water Supply: Public system El Community system C1 Private N Depth to Water Table..-.._ ft. Character of soil to a depth of 3 feet: Sand E] Gravel 0 Sandy Loam, Clay Loam ❑ Clay F1 Adobe❑ Hardpan C]Previous Application Made: (if yes,date_____._------_----) NoY New Construction-, YesA No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 7 �f Septic�Tank:�- Distance from nearest weil'�.D11_ Distant -fro -foundation_____=�J...._._.Ma brial___" ` No. of compartments._.,', P _, ."'Liquid depth__... ,/______Capacity... _........� Disposal Field: Distance from nearest well__/A&:�..Distance from foundation____'��-.�-.��____---Distance to nearest lot li e...... V&�pe mber of lines--------- Length of each line....�.Q__pp- _..___._.Width of trench._2.4' ___________________ of filter material...}-:___ Depth of filter material----/p_-----------Total length------1,260..______-------------" r Sdepage Pit: Distance to nearest well----------------------Distance from foundation-.'------------------Distance to nearest lot line__............... 11 Number of pits......•---------------Lining material-----------------------Size: Diameter------------------•....Depth_.._-__-------.__..._--._.._- Cesspool: Distance from nearest well-----------------Distance from foundation------------------Lining material------------------------------------- 0 Size: Diameter--------------------------------------Depth------------------------------------ ---------------Liquid Capacity------_---•--------------gals. Privy: Distance from nearest well__"_______________________________________"_._Distance from nearest building____-_....__.__-____._ 0 Distance to nearest lot line-----------------------•-------------------------------"--------------........-_......-----------•-•----•------------------------------------ RemodeI' red/or r pairin (describe):---- I -- " r ---- -- ..�-`^�"-'...".... _ Z_ ------- ...- - ---------------------------------------------------- =-------------------------------------------• - 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, andrul s and regulations of the San Joaquin Local Health District. I ^= r k . {Signed). {Owner and/or Contractor) By:....... -----------------------•-----------• -------------------•---_-------------------------------------------------------(Title)'----------------------------------------- ------------ (Plot plan, showing size of lot, location of system in relation to wells, buildings,'etc., can be placed on reverse -�- - r - 11 FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-------"-------------- ------------------------------------------ -------------•---------------- DATE------------------------------------_--------------------- REVIEWEDBY--------•------------------------------------ •------ ------------------•-..._. 1 DATE----...... ."""... r :.g..�--------------- BUILDINGPERMIT ISSUED------------------------------------ - O ---------------------------- DATE......................... ----------•---••-----------------•- Alterationsand/or recomme d'ations:--------------------------------------- ---------------"---- -----------------------------------•-••-----•---•---------._-----------.-----••----•------------- --------------------------•-.----- aY --------------------- ------------------------- ---------------------------••-•------•-----------••-------------------------•-•- ............... -----------------------------------------------------(r----------------------------------------------- --------------------------------------------------------------------- ------------------------------------- --------------------------------------------------------------------------------------------------------------- I _-�. � ."....6--.�-.-.------------------------ FINAL INSPECTION BY------ -------------••"""--- -- Date----------- �'" SAN JOAQUIN LOCAL HEALTH DISTRICT 134 Soulh American Street 300 Wert Oak Srreot 124 Sycamore Street 205 Wort 9th Street Stockton,California Lodi,California Manteca,California Tracy,California EB 4 REVI5E6 8.59 QM 6-6t ArLAO �' "