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FOR OFFICE USE: ----------------------- ------------------------ APPLICATION FOR SANITATION PERMIT Permit No.421x•.�-lJ... --------------------------------------------------------- (Complete in Duplicate) Date Issued --------.---.----..-------------------....----------- ..-_ This Permit Expires 1 Year Frorri Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and insta{I the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LO A IONIJ,�� Owner's Name .. / r --------------------------- ----- � ' �• Phone ------------------ --------- Address----- ------ -----_------ Contractor's Name------ - fir'------------I----------------- - ------- ----------------------------------- Phone----------------------------------- Installation will serve: Residence grpartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/__ Number of bedrooms _A__. Number of baths _/___ Lot size _"_________________________ Water Supply: Public system E] Community system ElPrivate R?'_D_`epth to Water Table 49 ftr . Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan C] Previous Application Made: (If yes,date-------------"------) No j' 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.) Q Septic Tarry: ,. Distance from nearest well_________________Distance from foundation--------------------Material_--------.----------.-----------------------._. No. of compartments---------- ----------"--Size-----_----------------- --_---Liquid depth--------------------------Capacity---------------- Disposal Field. Distance from nearest well---7�__Distance from foundation_:_�L�______.Distance to nearest lot line .` -_._.. _______-Len Length of each line____-__ �_`� Width of trench_.v`_Z--- ________________________ ��i,� Number of lines.__________�_____ __ g "�_Q- dType of filter material-/, IKK e epth of filter material__fe___._._-__-_Total length....sr-l3---------------------------__ f Xe_�_._- Disttaance to nearest lot li e---°�� ---- eepage Pit: Distance to nearest well_.__� �_______Distance from ''fou//,�ndation___ ") Number of pits--'-1.___.._.____Lining material____e,' d_ f _ Size: Diameter_,_, ..__.___.____Deptn_ _______________________ I Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material._-------._-________.________.__.___- ❑ Size: Diameter--------------------- ----------------Depth------------------------------- - ----------------Liquid Capacity----------------------------g �. Privy: Distance from nearest well-__.___.__________________---------------------Distance from nearest building_________.__________________.__...----_. ` 1 ❑ Distance to nearest lo+ line------ -------------------------------------- -------------------------------------------------- � 9 / repairing � 1 � s'�7,�� ""�-•-------------------------------------------------------------- ------ e-- Remodeling and/or re airin descr be _____________ i ---------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------- t --------------•------------------------------------------------------------------------------------------------------------------------------ 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, and rules and regulations of the San Joaquin Local Health District. (Signed) /•!�-_ ;+r.�- !i� !/�---- ------- - �r Contractor) -- Title Br------------------------------ ( ) ' (Plot plan,'shcwing size of lot, location of sys+e , relation to wells, buildings, etc., can be placed on reverse side). r'r1PARTMENT USE ONLY APPLICATION ACCEPTED B.Y�___.._._t___ ` - -- -- - - -- - -- --`----- --------------------------=-=--- ------ DATE-- ---�-��-^= ----- ---------------•--------- REVIEWED BY.----- �c. I' I � --------------------- DACE------------------------------------------- BUILDING ----- -------------------------------------BUILDING PERMIT ISSAD-- ---- /:-A-------------------------------------•----------------------------�----- - DATE------------------------------------------------------------- • + Al+erations and/or recomme9dationt1"__rZj------------- ----------------------- ----------------------- ------------------------------------------------------------------------------------- xz:,_ ., .,�.r = ---- ----- ------ ------------------------------------------------- . / .>r. -----------�----- -- -- ------ ------ - --- � -------------------------------- ---------- = 5 'I ----------------------------------- ---------- --------------------------------------------- ---------- -=--------------------?-------•- ------------------------------------------------------ FINAL INSPECTION BY:. ---'-°h ----------- ------ Date _`j -- -- - -- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West grit Street stocktan,California Lodi,California- Manteca,California Tracy,California F.P.C O" I a