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FOR ..QFFICE USE: 1" --- -------------' 'p APPLICATION FOR SANITATION Permit No. --------------------------------------------------------- PERMIT (Complete in Duplicate) Date Issued -------------------------------- This Permit Expires 1 Year From 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 County Ordinance No. 549, JOBADDRESS AND LOCATION---------1--17--------&- 1/------- ------ --------------------•------------------------------------------------ Owner's Name------------- --a -------- --------------------- --------- -- --------- Phone------------------------•-------•--- Address--------------------------- y� - > , -------- --------------------------- Contractor's Name ---------•-------- Phone 1�� /�.L �1� -------------------------- ----------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _-- _ Number of bedrooms Number of b 1.aths _-/_ Lot size ------- a_f1� -zs---------------------- Water Supply: Public system �C Community system ❑ Private ❑ Depth to Water Table yft. 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 ❑ No19FHA/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----------------------- Disposal Field: Distance from nearest well-_�� _Distance from foundation__R.�--------Distance to nearest lot line---�_-_.-.--. Number o Length of each line--_,,_d. 3_�-�._-Width of trench o � -_---_ Type of filter material._t54Depth of filter material_-_,/9 -------Total length----------_--------------- ------ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line--_----------__ "s ❑ Number of pits----------------------Lining material---------------------f-.Size: Diameter------------------.....Depth-.------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------.------. r ❑ Size: Diameter--- Depth ---------Liquid Capacity---------------- -------gals. Privy: nn . Distance from nearest well---------------_-----__--------------_----------Distance from nearest building_----------------------------_---------. ❑ Distance to nearest lot line-- --- ---------------------- --------------------------------------------------------------------------------------------------------- �f Remodelingand/or repairing (describe):----------------- ------------------------------------------------------------------------------•------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ` ------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stalaws, and rules and regulations of the San Joaquin Local Health District. (Signed)------------ --- -- -- --------------- --- ---t---- __ -----------------------------------(Owner and/or Contractor) . `` (Title) -- ---------- (Plot plan, showing size of lot, loca ion of system in r ation to wells, buildings, etc., can be placed n reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- ---------------------------------------------------------------- DATE-..--3:7/-,S7- ATE-----3--/-'S7- (c, `1�------------------------ REVIEWEDBY---------------------------------------------- ------------------------------- ---------------------------------------------- DATE------------------------- ------------------------------- BUILDINGPERMIT ISSUED-------------------------- ----- ------------------------------------------- - ---------------- DATE------------------------------------------------------------- Alterationsand/or recommendations----------- ----------------- --- -------------------------- -------------- -------------------------------------------------------------•---------------- ----------------------------------------•-- --------------------------------- ------------------------I------------•----------------------------------------- -----------------•------------- -------------------------------- --- ----------- ------- --------------------------------•--------------------------- --------- --------------------------------------- ---- ------------- -------------- - - -- - - --------- -------------------- -------- --------- ------ FINAL INSPECTION BY:-.---- - ---------------- Date-- --`-------- - -------------------------- ---- ---- ------------------- - .. SAN JOAQUIN LOCAL.HEALTH DISTRICT 1401 E.Hazelton Ave. F 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.F.CC. *°'