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FOR OFFICE,USE: ------------- --- °`� APPLICATION FOR SANITATION PERMIT Permit No. . .f :�', ------------------- ---------------------- ----------------- ` --------------------- ------ ------------ ------------ (Complete in Duplicate) Date Issued _,�t_-z'-_-�� _-_-----_----_--____________-_____________-___ "\ 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 r-49. JOB ADDRESS AND LOCATION--- '� � � /1. ----- ----- --------------------------- ----------------------------------------------_ � --- Owner's Name-- / ------------------ ------ Phone------------------------------------ Address-------------- .......eoto'�s , ---- -------------------------------------------------------------------------------------------------------------------------------- - Contractor's Name---------- - -------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel`'[] Other ❑ Number of living units: __/_ Number of bedrooms _PZ_ Number of baths _. -- Lot size f�V 14 -f------------------------- Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table _�v"Af+ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe @a-"fTardpan ❑ Previous Application Made: (If yes,date___________________) No Qi New Construction: Yes ❑ No [g-'FHA/VA: Yes ❑ No Zj., TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sytic.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____.._______-_____-Distance to nearest lot line----------------- i115A,�V Number of lines___________________________________Length of each line----------------- ---Width of trench------_-------------__-_-_.____-____ Type of filter material ____________--------____Depth of filter material __.-----------_-----._Total length-------------------------------- Seepage ____________________.--____-_Seepage Pit: Distance to nearest well--------- --------Distance from fou dation__/t G�.___.Di tan e to nearest lot line__ -- �' Number of pits_-__/r-_________Linin material__ f� Size: Diameter__: p !►-� -- g -- -De the��e' _- � Cesspool: ..,Distance from nearest well______________Distance from foundation--------------------Lining material______ _________ __________________ ❑ i:e: Diameter--------------------------------M-----Depth------ -------- --- - -- --- ------- --------Liquid Capacity_--------------------------gas. Privy: Distance from nearest well__________________ ______________________________Distance from nearest building__----------------------------._-______-_- ❑ Distance to nearest lot line-------------- ----------;---------•---------------------------------------------------------------- }� Remodeling and/or repairing (describe)=------------- f f/it, 'fie--"--------•------------------------------------------------------ 1b --------------- ----------------------------------------------------------------- ----------------------------------------•--------------------------------------------------------------------------------------- ------------------- ------------------------------------------------------------------------------------------------------------------------------------------------ ------------------- I 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. _ _- ( or Contractor) (Signed)---- -- -------�------ -- -- --- - --------------------- --- ------------- -•-------- ----------------------------------- - By:-------------------------------------------------------------------------------------- -- --------------(Title) -L - ------ - --- - -------- (Plot plan, showing size of lot, location of system in relatio wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------- - ------------------------------------ -------------------------------- DATE---- = 1�= tea ®-------------------- REVIEWEDBY------ ---------------------------------------------------------------------------------------- ---------------------------- DATE-------------------_-------------------------------------- BUILDINGPERMIT ISSUED---------------•--------------------------------------------------------------------- ------ DATE----------------------------------------------------------- Alterations and/or recommendations:____.____:__.___-___ _ tl4------ �%z_ �---D --------------,;e----------------------------------------------------. -------------------------------------------------------------------------------- --------------- --------------------------------------------------------- --------------------------------------------------------------- ------------------------------------------------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---- FINALINSPECTION BY-------------M-r-1---'f---------------- ---------------- --- Date----- -fl`'"1 °---------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CO.