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F FOR OFFICE USE: -- `4y __ _r- ----- ----------- ---- --"- - APPLICATION FOR SANITATION PERMIT Permit No. s .. ' -------------------- -------------- ---------- --------- (Complele•in Duplicate) - ...... ------ -- -- - - --- This Permit Ex fres 11-Year From Date Issued Date Issued ' Application is hereby made to the San Joaquin Local Health District for a permit to co nstucttd alf the work herein described. This-application is made in compliance with County Ordinance o. 549. •R �` Ssr��''t rcc� _ JOB ADDRESS AND LOCATION---V -- -.-- --,. [ncJ Owner's Na ,/f 2. � = ------ -------- Phone.----------------------------•----- i Address --------------------------- - ----, ----------------------------- ---------------------------------- - - Confractor's Name.... � ... .. . . .... .... --------------- Phone----- - Installation will serve: Residence 'MI"Apartment House[] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -- Number of bedrooms .Number of baths.../__- Lot size ----- --- Wafer Supply: Public system ❑ Community system ❑ Private EN Depth to Water Table ------ . ft Character of soil to a depth of 3 feet- Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [Adobe E] Hardpan ❑ Previous Application Made: (If yes,date......-...-.-...... J 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 ----._- El - No. of compartments---- -- ---- ---------Size------•------------- -----------Liquid depth--------- ------ .......Capacity----------- : Disposa Field: Distance from nearest well-...�d......Distance from foundation------1.-EJ-.......Distance to nearest lot line__!5' Number of lines C ------Length of each line-- --- ---- -v j----------.Width of trench----- Type of filter material...- _-V__S_S.r---_--Depth of filter material-.__.,1-f..........Total length..._-�3'd---.----_- tM ------------------ ` See pa Pit: Distance to nearest well_..:_r'.�.a--......Distance •from foundation-----l.p- ------Distance to nearest lot line---- {dumber of pits--- -----t---------Lining material---`S`�2- --,--- Size: Diameter__...��..3.._ - Depth__'.`r-- -------------- Cesspool: -----Cesspool: Distance from nearest well ........... :'Distance from foundation..-._-_.._.._-_- ..Lining material___--------------.................. "� "❑ Size: Diameter. .. .. --- -- ----- ---- -------Depth....... ------------------------------------------Liquid Capacity-----------------_--------gals. f ' - Privy: Distance from nearest "- -------- `---- - ---------Distancd from nearest building {❑ Distance to nearest lot hi e---------------------- --------------------------------------------------------------------------- v Remodeling and/or repairing ld�escribe):. ._- t •------------------------------ ----------------- - - - -- a I hereby certify that I have prepared this application and that the%work will be done in accordance with San Joaquin County ordinances, St laws, and rules and regulations of the San Joaquin Local Health District. (Sigried)- -- ---------I-Qwrer-and/or Contractor] Sy:-------- -- ...c-= ------- ---- --- - ---�--- --------------------------- ---- -----(Title)----- ---- -------------. ------ - - -- - ---== (Plat plan, showing size of lot, Iota+ion of system i relation to wells, buildings, etc., can 6e placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY. -- -- -- J ---------------------------- -- -------------- DATE 1 � -_ 9--- -7 --- - --- - REVIEWED BY --------------------- --- - ------------------------------------- -- ----- DATE ..BUILDING PERMIT ISSUED-------- -- - --------------------------------------------------- ----------------------------------.- DATE Alterations and/or recommendations:..-.____.....-__.--...- . O - �c --- - - ---------------- ---- --------------- ------------------------- , FINAL INSPECTION BY:. is .�' �Q'�/Ptl/� Date..' PrP. .... SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Naislton Ave. 300 West Oak Street 724 Sycamore street 20.5 West 91h Street � Stockton,California Lodi, California Manteca,California Tracy,California E.N.92M 1-67 Vanguard Press r. '