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FOR OFFICE USE: t -_ -`- -.�-r___ , APPLICATION FOR SANITATION PERMIT Permit No. -------- --- -- - ----------------------------------- (Complete in Duplicate) ____________________ -. -_ This'permit Expires 1 Year From Date Issued 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 Count Ordinance No. 549. JOB ADDRESS AND LOCATION ---T--�'- --- --------------------------------------------------•---------...........--•---------------------------- 3 1 Owner's Name------- ----- ------ ----•---- -•- - Phone------------------------------..... Address------------------ --------•-•------•;-------- - .....--------------------------------------;---------------------------------------------------------------•---•--•------------ Contractor's Name ---------/Lv-\ .-- - ---- .s.1----r-�-----•--------•--------•--------------------------------•- Phone Installation will serve: Residence [2-,Apartment House ❑ Commercial ❑ Trailer Court:❑ Motel ❑ Other ❑ Number of living units: __1.... Number of bedrooms' --- Number of baths -_1--- Lot size .-- -------------- Wafer Supply: Public -system EU—Community system ❑ Private ❑ Depth to Water Table 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 J]"-No ❑ FHA/VA: Yes ❑ No �9— TYPE OF INSTALLATION AND;SPECIFICATIONS: (No septic fank'or.cesspool permitted if.-public sewer is available within 200 feet.)., Septic Tank: Distance from .nearest well/ia-glo __Distance from founclation_-_57-V-- / ----------Material No. of com artments-..-_ ..----Size----_. _S(,5 y__. --.--_Li Liquid de th_---. -Ca acit �y a P q R P Y Disposal Field:.. -Distance from nearest wellrru_,Vq---_D.istance_from foundation__O�-----------Distance to nearest lot line._..-----_. Number of lines___=1__-_..---- 1-.- Length of each fine_--__ Width of trench----..------ y-`------- CY ---- �.Type of filter material-_- _ -_ Depth of filter material..-_ ---`--.-------Total length--------- Q----------------------- Seepage - _----- Seepage Pit: Distance to nearest-well_!2-Q&e------Distance from foupdation-----`--_____...Distance to nearestjof line----S.S'_--.-- Number of pits_____---2------------Lining material_I�R.G _ :.Size: Diameter-_----;Z...........Depth_'- -``--__---_ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material.-----.-------.-----. El Size: Diameter------ r-=--------------------------- Depth---------------------------------------------------.-Liquid Capacity. gals. Privy: _ Distance from newest well-------------------------------------------------Distance from nearest building------------------------------- ---- -.. ❑. Distance to nearest lot line--------------- ------------------------------------------------------ --------------------------------------------------------------------- .� , Remodeling and/or repairing (describe)------------------------------------------------------------------------------------------------`--------------------------------------------------------- 1 -- . . - a — t ------`--------------------------------•--------------•-•-•-------•-•---------------•---------------------`-----••---•`--•--.._..........----...........------------`----•--------..----.-_--- --- I hereby certify that I have prepared this application and the+ the work will be done in accordance with San Joaquin County ordinances, State laws,'and rules and regulationf the an Joaquin Local Health District. - (Signed)---------- ---------------------- -•------.-------- -`------------ ------)Owner end/or Contractor) By:---------------=----- --'•----------------------- ---------------------------------------(Title)-----------------------------------•-------- - - -------------- Q (Plot plan, showing sizerof lot, locationrof system in relation to wells, buildings, etc., can be placed on reverse side). I FOR pEP RTMENT USE ONLY APPLICATION ACCEPTED BY --- _ == DATE -- _.-- /-- ............... =REVIEWED BY-----------'------------ ----------------------------- DATE------------------ ----------------• ------•-------------- BUILDINGPERMIT ISSUED------------------------------------------------------------- •-------------------- `D_ATE.------------------------------------------------------- Alterations and/or recommendations '--------------- ._. .. .......... --------------------------------------------------- --------••-------------------------------------- •--------.-...-..---•--------••----------------_----.-.-•---- 4 / a � . --------.----------------------------- ----------------------------------------------------•-----•---------------- ----------- ----------=---=---=--- ----- ------------------ - - - ----------------- --------------- ----------------------- FINAL. INSPECTION BY --- i Date ��=& y SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street •.,%Tw, 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E8.9 REV16E0 a-99 F.P.CO.2M 6.60 = J