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F R OFFICE USE: - N - --�-- -_ Permit No. ---;•----------------•- .. ---._ APPLICATION FOR SANITATION PERMIT ---- ----------------- (complete in Duplicate) Date Issued ------- - ---------- - -_--- ------- This Permit.Ex ires 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.--e4 . J JOB ADDRESS AN LO N_ -- ------------ -------------------- ---------------------------------___---- -r"• Phone ----- Owner's Name___ _ _•"""--- ---- ---- •------ --------- ---------------------------------------- ------- ------- --- -- - r t ---- -------•-----•• Phone----------------------------------- Address . � '____________ _-_._____ Contractors Name-------_--- 4' Other Installation will serve: Residence ®<Apartment House ❑ Commercial El Trailer Court [I Motel ❑ C3 Number of living units: -1----- Number of bedrooms _Z Number of baths l- Lot,size � X Depth to Water-Ta41,JZ— ft. Water Supply: Public system [ ommuriity system ❑ Private ❑ p ardpan ❑ Gravel San oam ❑ Clay Loam ❑ Clay ❑ Adobe Character of soil to a depth of 3 feel: Sand ❑ ❑ �HA/VA: Yes ❑ NO- Previous o Previous Application'Made: (If yes,date-------- ---------1 No New Construction:>•Yes ❑ No t TYPE OF INSTALLATION AND SPECIFICATIONS: (Na septic tank or cesspool permitted if public sewer is available within 204 feet.]from foundati ----------------------------- -------------------- Septi nk•1 y Distance from nearest well-__"_------------Distance on"_--______-___ Material__________Capacity"-____-----___:-- --_ f No. of compartments------------- ------------Size--------------------------- Liquid depth Dispo Fiel istance from nearest:well_ --------------:Distance from foundation_____...____:__._.Distance to nearest lot line }. Number of:lines--------------�---- -------------Length of each „ "Width of trench . ,m ---------------------------------- i � -_ De th..of filter material-----------------=----Total ,lengt --------- r . ,Type;of filter material___"-�._.___"_______-_-" p •�'� Di nce to nearest lot iineo-"_-_.___---- O _ i, �i I Seep g r : Distance to nearest well_- r; "Distancrom foundation___._ _.�______. De th".'_2�S ------- v _Linin ma#erial_./I-_QCT-< = Size: Diameter_" p :Number of pits-�_._�-------"--- 9 . Cesspool: Distance from-nearest well"___ _____-Distance from foundation..---- Liquid d Capacity._ .__----------------- - --- ❑ Size: Diameter, _ A--------------- Depth- Distance from .nearest building----------------------------------------- Privy: Distance from nearest well_-.---"------- -----.--- ❑ Distance to nearest lot line-'=------------------- ------ -------------------- a ----------------------------- 3 _ ..___"-.__.___---- - Remodeling and/or repairing (describe}:__________--.--"-- - -----------_-------___".--.___._- .____•________-•---•---"-----_-----4---"-___"______________ -".-.""""_""__ ____----------------------------------- -------------------------------------- �.] �a _--____ _ V - .. ' _---------------------------. _ _______"-___-_____"-_____"___"" "__ _ hereby certify that I have prepared this np of a Sand to ui hl-calk etel heDistrict.n accordance with San Joaquin County ordinances, State laws, and rules and regulations nr ---- er an Contractor) "-"----[Own and/or i 4 t (Signed) "----------- ------- •----- - ---•--- -t -----•-- •-----------•---- ------(Title}--=------ ----- ----------- --- (Plot plan, showing size of lot, loco+ton of stem ' relation to wells, b dings, a+c., can'be placed on reverse.si e. I } FOR DEPARTMENT SE ONLY 12 APPLICATION ACCEPTED BY----;--•------------------ -- h/-- ------------------------ DATE_.------- ------ = ------------------- DATE--- --------- -----•---- ---------------------------- iREVIEWED BY------ -------------------------------------- ----- ---- ------ DATE------------------------ ----•=----------- ----- ---------- BUILDING PERMIT ISSUED.__.------ -------- ----------------- f Alterations and/or recommendations-----_------------------ -- ------------ ----- . -- -- T--- ------------------------------ 1 ._. . . - - Date..............- -- - ---- - - - --- ------------------ ----------- FINAL INSPECTION BY:--- _- -------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1801 E.}laseltvn Ara. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California r ES 9 REVl9EP a-S9 3m 3-163 F.P.CO. i