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FOR OFFICE USE D O S—r 4o._&f APPLICATION 1=0R SANITATION PERMIT Permit No. ----------------------------- -------- ---- --- --- (Complete in Duplicate) JO�jf� Date Issued ------- --- This Permit Expires 1 Year From Date Issued --------------- 3 Application is hereby made to the San Joaquin Local Healfh District for a permit to cons5".. EDA herein described. This application is made in compliance with County Ordinance No. 549. 6"4 wp�-K JOB ADDRESS A D LOCATION- J-- -- .----••--- Owner's Name- --------- Phone-------- n --------------------------- --------------------------------------------------------------------------------------------------------- Address e ------- Contractor's Name --- - -•------ - -- ---------•----- Phone---------------- ---_-_--------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ -Trailer Court ❑ Motel ❑ Other [a' Number of living units: -------- Number of bedrooms -------- Number Number of baths -------- Lot size -----------------------------------_-----------------.--,_ Water Supply: Public system ❑ Community system ❑ Private [Depth to Water Table - U 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--------------------) 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----------------------- Dispos�Fie#d: Distance from nearest well -'-," /____Distance from foundation------ to nearest lot line---------------- ® Number of lines------------6------------- ----Length of each line------/p a-- -------Width of trench----_'�------------------------- Type of filter material__, p g �.�-------�De th of filter ma#erial____._.Jr�`--�-------Total length See pa a Pit: Distance to nearest weO------- D-u- ----Distance from foundation------ V. -- Distance to nearest lot line--t--------- Iv Number of pits------ ----------Lining material----a 1C----------Size: Diameter-------�d -__--Depth---- ------------------- I-(,' Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material------------------------------------- O ❑ Size: Diameter--------------------------------------Depth----------------------------- ------------------Liquid Capacity-------------------- -- gals. Privy: Distance from nearest well-----------------------------------------------._Distance from nearest building------------------------------------------- ElDistance to nearest lot line----------------- ---------- - --------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe);--------- --------------------------------------------------------------------------•-------------------------------------------•-------- -•---•--•-----•----------------------- -•--------------------------------------------------------------------------------------------------------------------------------------- --------------------------- -- --------------•-----••--------------------•------------------------------•-------------- ------•------------•-----••---------------•------------------------------------------------------------------------------------------ ------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------0� 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. JQ (Signed) � G � c--- ------- -- ------- -- ------ -- --- ------ ----------- nd or Contractor By:----------- --------- R- `_t__Q--- ---------•-------------------------------------(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 BY----- - ---------------- -- - .c ' ----------------------------------------------- DATE- © ----------------- REVIEWEDBY--------------------------------------------- -------------------------------------------------------------------------------- DATE----- -------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------ ------------------------ Alterations and/or recommendations:--------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------•---------------•--------------------------------------- --------------------------------------------------- -----------------------------------•----------•------ -------------------•-------------------------------------------------------------------------------------------•--- ----------- ------------- --------------•- - --------•------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------- --------- ------------------------- ---------------------------------- ------•----------------------------------------------------------------------------- -------------------------- FINAL INSPECTION BY:.-. - - - - - - Date. Z$' tv4 0 ------ - SAN JOAQUIN LOCAL HEALTH DISTRICT 1801 E.lfaaelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 4th Street Stockton,California Lodi,California Manteca,California Tracyr California ES 9 REVISED B-59 3M 3-'63 F.P.CD.