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FOR OFFICE USE: _________________________________________________________ APPLICATION FOR SANITATION PERMIT Permit No. ---------------------------------------------- ---------- (Complete in Duplicate) This Permit Expires 1 Year From Date Issued 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, f JOB ADDRESS AND LOCATION. I- a(._- -le __!__ , /, __ ' L45?!� f'x_ 'a Owner's Name-------!.- _f� ?G>�7` .C ---------------------------------------------- - - --------------------- ---------------- Phone-4 ... Address----------------------- ---- --- -----------------------.---_-------------------------------------------------••----•- Contractor's Name--------------- , ----------•-------------------------------------------------------------------------------------------- Phone------------------------•---------- Installation will serve: Residence Apar+ment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ----I... Number of bedrooms _ ._ Numb� pth r of baths ---/---- Lot size ___� __?� 2<s - ---------------------- Water Supply: Public system E] Community system El Private to Water Table _6.- ft. Character of soil to a depth of 3 feet: Sand [] Gravel ❑ Sandy Loam ❑ Clay Loam [❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: (If yes,date...-_[457.7-1 No ❑ New Construction: Yes �o ❑ FHA/VA: Yes ❑ No i❑•�� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is availa6le within 200 feet.) J [ Distance from nearest well -_-_--Distance from foundation____ _ ___.__.Mateial-___r�Septic Tank: /- � 4ar__-_ ----- No. of compartments--------- -------- Size___.______-_____-_-____-.-.___Liquid de th-_.______...____..______- Capacity X_�_w Disposal eld: Distance from nearest well---- Distance from foun a ion _�Q Distance to nearest lot line.._- _._____ Len th of each lin Width Number of lines______, f f 9 � �} dth of trench l Type of filter materiaf'` -AD- Depth of filter material__-_._ -------------Total length__-. Seepage Pit: Distance to nearest well.__-----------_____---Distance from foundation--------.-----------Distance to nearest lot line_______.__-__.-- ❑ Number of pits----------------------Lining material----- --.-____------.Size: Diameter-----------------------Depth-------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--.-----____--__-_-_-___..________.__ t ❑ Size: Diameter---- -------------- ----------------Depth----------------- ------------ ------------------Liquid Capacity- -------------------------gals. 1 Privy: Distance from nearest well----------------------------------------_ -._ --Distance from nearest building_-_.---------------------------.-----.-. � ❑ Distance to nearest lot line.- -------- --•----------------•----------------------------------------------------- ----- Remodeling and/or repairing (describe):--------- ----------------------- -----------------------------------------••----•---•-----------•------ ----------------------------------------------- k ______________________________________________________________________________•___________.___________________.________________._.______________-___-_--.-____--------__..____----____-.-.---_-_..--_-___.___________-_...--.- --------.-.___________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________..___-_-_________-___________-----.-___________________-____--_--------_--_..-..---.----___________-____._______-_____-_____-__-_-_--__--------________._-.______-______--_----_.__-----------------..----. I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County § ordinances, St to laws, and Vrulesnd re ulations of the San Joaquin Local Health District. (Signed)___ _____ ._________.______ ____ _.__._ -.{Owne nd/or Contractor) " BY:-------------------------------------- ----(Title)----------------------------------- --- --- - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can 6e placed on reverse side). le�o-- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED B = ---- --- -- ---------------------- ---------------------------------------- DATE-- /4_`a1_ --� REVIEWED BY ./----- -- ---- --------------------------- ---- — DATE------------------ - ------------ - ----- BUILDING PERMIT ISSUED------- ------------------------- ------ ---------- --- — - DATE------------------------------ Alterations and/or recommendations:-------------------------------- ---� - __ --- --- ------------ --------•-------------------•------------------------------------------- L"`._ -- - -- -- - ---------------------------•--------------------•-•------•---------..- ----------------------------------- •---------------•-------------- �;° ----- --- - - - --- ----- -- --- ---------- ----- ----- --------- -------------------------------- ------------_ ---• -- , ) FINAL INSPECTION BY:-- -............ - -- ------------------------- - --- ----- Date------- --- - ---- -- ------ -------------------------------- 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,