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FOROFFICE USE: --------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .�7... �.1/... --------------------------------------------------------- (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 with County Ordinance No. 549. JOB ADDRESS AND LOCATION_ .--a :�o______________ Owner's Name________ _ ,. . f -- -- -•--•- - ----- ------------ -------- Phone---------------------------------- Address ---••----------------------------- ---- -- --- Address-----i--- �[3G y...--- ---------- ------1--------------------•------------------------•-----------------------------•----------- iContractors Name- ---�.-..r��..: -------- ------ Phone---------- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1____ Number of bedrooms _ f �__ Number of baths ___�_ 1_ot size __. _�t-=__"r—rsZA.�----------------------------- Water Supply: Public system ❑ Community system ❑ Private ; Depth to Water Table ----- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ErClay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------I No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ 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_----------_-___Distance from foundation--------------------Material--------------------------.__-__-----.________- ❑ No. of compartments------------------ --:_Size--------------------------------Liquid depth.------------ -- -------- Capacity_-__---- -------- Disposal Field: Distance from nearest well_--._. S-�_Distance from foundation____._ _-_-_-.Distance to nearest lot line_____.._... KNumber of lines---------------i------ Length of each line--------f- -Q--------------Width of trench------7?�n_'-.................... Type of filter material-----5-r*�-----------Depth of filter material--------!_-Q_"--___Total length--------1__�----------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_---_-_.__-___.-_ ❑ Number of pits----_-_ _Lining material-----------------------Size: Diameter-----------------------Depth_____.--_-______________.________ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- F1 Size: Diameter----r--------------------------------Depth------------- ------------------ -----------------Liquid Capacity_----------;-------------gals. Privy: Distance from nearest well--------------------------------------------_----Distance from-neasesf.:building_______________________-_------_-.___- ❑ Distance to nearest lot line------------------------------- ------ `------------------------------------------------------------------------------------. f Remodeling and/or repairing (describe)- ---------it------------------------------------------------------------------------------------------•--------------------------------- -------------------------------------------------------------------------------------------------------------------------------------•-------------------------------------- ----------- 1 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. (Signed) , ---------- -------- -----------------------------------------------------< —. ---.-'&- ner and/or Contractor) ---------- gY: ---------- •---------`----- -----------------------------------------------------(Title)------_7------------------- --------- - - -- - ------- (Plot plan, showing size of lot, location of system in rely ion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- - --------- ------------------------------------------- DATE ��? �� ----------------------- REVIEWEDBY--------------------------------------------- ------------------------------------------------------------------------------- DATE---.-----------------------------------------------------... BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterationsand/or recommendations:---------- -------------------- - ------- ---- -------------------------------------------------•-----•-----------------•-------------------•-------------- -------------------------- ----------------------------------------------------------------------------•------ ---------- ----------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------ FINAL INSPECTION BY:---- DateO.'- ------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E,Hasellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISED a-59 3M 3-'b3 F.P.CD. - J