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FOR OFFICE USE: 4l J_ -1a Z/ s-- ------------------- APPLICATION FOR SANITATION PERMIT Permit No. •_.�7.. ..I` -___._____ - - --_ (Complete in Duplicate)--- ---- --------------- - - - liDate 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. JOB ADDRESS AN ATIO ... ;�___ __________�v____-- ------ ------------- -----------------------------------•--- Owner's Nam ----- -�-- -•------- ---• --------•-------- ---------------•--------------------------------------------------------------- Phone----------------------------------- Address------------------- �,/ ---------------i ----------------------------------------------------------- Contractor's Name----- - .. -- "'-.L --- ---- ----- ----------•--•--- Phone----------------------------------- ! Installation will serve: Residence (Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ____1__ Number of bedrooms =2--- Number of baths /------ Lot size ---lG-_P_X_lA-A------------------------ Water Supply: Public system g--tommunity system ❑ Private ❑ Depth to Water Table '¢0_ft r Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobeardpan ❑ Previous Application Made: (If yes,date--------------------] No [ New Construction: Yes ❑ No Er---r-9A/VA.. Yes ❑ No 0� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sept Tank: Distance from nearest well----------------_Distance from foundation--------.-----------Material__-_-------_._.-____._.__---________..______----. No. of compartments--------------------- ----Size------------------------•-------Liquid depth-------------------------Capacity-•--------------------- i posal ield: Distance from nearest well. ----._Distance from foundation__-4--------------Distance to nearest lot line.__'f----------- Number of lines__ _____ - I------------------------Length of each .6---------------Width of trench-----'Z ---------------------- Type of filter material-__�f CCA_Depth of filter material__./_$:__ ______.Total length------ o----------------------------- Seepage __ __________________ _See a e Pit: Distance to nearest well ..__'—___.-______Distance from foundation___/�----------Distance to nearest lot line--�__ ---._ b!�� Number of pits_____.._----._._.__Lining material______ _ _ _4 _Size: Diameter-3_�_r_._-----_-Depth--..-2j-`----___--__-- Cesspool: Distance from nearest well--------------___Distance from foundation--------------------Lining material__________--______-_----.___-____.___. U ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity--- -------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_-_---_________----_-_-__________-_.___. ❑ Distance to nearest lot line ----------------------------------------------------------------- ----------------------- ---------------------------•----------------- Remodelingand/or repairing (describe):------------- -------------------------- ---------------------------------••-------------------•---------------------•------ ---------------------•---- ----------------------------------------------------------------• •-•------------------------------------------------------------------------------------------------------------------------------------------ -- --- Y - ----------------------------------------------------------•--------------•• -----•----•------------------------------•--------------•----------------•-- -------------•----- -- ---..-----•-------------------- i 1 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)---------------------------------------------------- (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). OR DEPARTMENT USE ONLY c� APPLICATION ACCEPTED BY� _��k _ DATE____ - ----------------------------------------- - REVIEWED BY--------------------------------------------- -----------------------------------------------------------------• DATE-------------------------- ------------------------ BUILDINGPERMIT ISSUED----------------- -- ------- --- - - DATE------------------------------------------------------------- ----------------------------------------------------------------------- Alterations and/or recommendations—— = ..v- - -------- -- - --- ---- ---------------------------------------•--------- --- -- -----------•----------• -----------•---------------------------i- ------------------------- -------------------- FINAL INSPECTION BY:---1-K. .. ----•- Date.... ✓�r� -------- - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 405 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California Es 9 REVlSEC 8-59 3M 3-'63 F.P.CC.