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FOROFFICEb - - 1 __.__..--___.. Y -APPLICATION FOR SANITATION PERMIT Permit No. -------------- i I q I (Complefe in 07uplicafe) This Permit Expires 7 Year From Date Issued Date Issued Application is hereby made to the an Jo Uq� Local Health District for a permit to construct and 'install the work herein described. This application is made in compliri •itlCbunty Ordinance No. 549. JOB ADDRESS AND LOCATION______ --- f I--- "4x �e_r Q. h P =/'� `(----� _+1 _ -------------------• ------------- - � ) Owner's Name--------�1�Q ----•- - �--•----- l fir;---- --------- ------ Phone--------------------------- ------- f Address------------------ a� � �� --•�0��_�.`l"[) ~ //�� } -------------------- Phone------------------•---------------- 5 Contractor's Name------•-------t�_la_��"�c=--_- -a:4'_-l�-.... - ----��'-� - - --- -------------------------- Installation will serve: Residence Apartment House ❑ ,Commercial [] Trailer Court ❑ Motel ❑ ther ❑ / qWateNumber of living units: _/---- Number of bedrooms __ --- Number of baths ________ Lot sizer�---x� r Supply: Public system ❑ Community system ElPrivate I-] Depth to Water Table �___ ft, •�'`� x ) Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ ,.Cla/ ❑ Adobe [Hardpan ❑ Previous Application Made: (If yes,date---------------------) No � New Construction: Yes ❑ No CW FHANA: Yes ❑ No 1Q/ TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or cesspool permitted if pubiic� sewer is available within 200 feet.) Septic Tank: Distance from nearest well-5-P-_______Distance from foundation_ __ - �P LCA` Q e� ��. Material- ---- -------------------------- No. of compartments-__-- -- ISize.- Liquid cl`pth-----_---� �--Capacity---- - ------------ Disposal Field: Distance from nearest well--. � Distance from foundation.-ID_�__-___.Distance to nearest lot Gje__-_�---__ Number of lines---------- -------------------- - Length of each line-_.---.-----2r0---J�----Width of french------4 -•- --- ----------- Type -------- Type of filter material-57eA1w*, Depth of filter material_-.:-19-----___.Total length____-________-7_�_-f_--------- _ Seepage Pit: Distance to nearest well----------------------Distance from'foundation------------------- Distance to nearest lot line____...______ ❑ Number of pits----------------------Lining material-----------------_-----Size: Diameter----.------------------Depth--------------------_-- ------ 10 Cesspool: Disfance from nearest well--_-------------Distance from foundation--------------------Lining material------------------------------------- El Size: Diameter--------------------------------------Dept h-,--- -------------------- ---------------------Liquid Capacity-------------------------' gals.o Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-------------------------.-_ ❑ Distance to nearest lot line Remodeling and/or repairing (describe)-------------------- - �.tf-_ ----------------•----------- '------ ": i ---- -- - - ----------- -------------------------- - — - 3 r-------------------------------------------------------------------------------- --------------------•--•----------------------------- _- ------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County i ordinances, State laws, and rules and regulations'of the San Joaquin Local Health District. (Signed)---------- i = � ------- -------------------;-------------------------------------------------(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 side). FOR DEPARTMENT USE O s APPLICATION ACCEPTED BY --- ---C--- DATE----- �r �� - (P REVIEWED BY-------------------------- DATE ---------- ---------------------------- BUILDING PERMIT ISSUED ------------------------------------------------------------------ DATE Alte ations and/orf'recommendations:-_- - -- - Ja-�,-6r � ti ------------- �` FINAL INSPECTION BY:..---- i ------------------------------------ Date---/'O/ 41_111 11... SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 sycamore Street 205 West 9th Street Stockton,California Lodi,California i` Manteca,California Tracy, California ES 9 REVISED 8-S9 3M 3-'63 F.P.CD.