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OFFICE USE- ------------- ------- f ------------ ------------ --- --------- APPLICATION FOR SANITATION PERMIT Permit No. ..... .. .......... -------------------------------------------------------- (Complete in Duplicate) // Date Issued ----- ----------- This permit Ex ires 1 Year From Date'lsiued I 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 AND LOCATION _ ` � __..3 . l Owner's Name-- _l '6.,�?_. _..1.l-Cr_fi��4•-------------------- Phone. Address-------J_ Y---- ��. �----------------------------------------------------------------------------------- ----------=----------------------------------------••-------- - -------- Contractor's Name------Q.,�Qr. -------------•----------•--------•-------- Phone, 1.:.,a--/-; —� Installation will serve: Residence Apartment House ElCommercial ❑ Trailer Court '❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms 3---- Number of baths ---it. Lot size ______________________r.....-_a--------------.________-_-_.- Water Supply: Public system R] Community system ❑ Private ❑ Depth to Water Table -------- ft. I Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑' Clay-[] Adobe Hardpan Previous Application Made: (If yes,dote____________________l No ❑ New Construction: Yes ® No ❑ FHA/VA: Yes'❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No ieptic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well________._-Distance from found„ation____ Q_____.__.Material--- -LSl-fe�Q --------------- a` ______Size_....c _X__9.`.4-----Liquid depth-------IV2_�� ----Capacity---- No. of compartments______._.-.-__ Disposal Field: Distarice from nearest well--_ '__,__-___._.Distance from foundation.___14---------Distance to nearest lot line..-44't......... Number u --------------- Length of h hc _____-__________ T------ Type of filter material___ 06C__ Dehoffltermate�al_.�« a- Total length ----------------- Seepage Pit: Distance to nearest well----------------------- Distance from foundation--------------------Distance to nearest lot line__:__________ I Number of pits--------- -- ------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance fromfoundation-----------.--------Lining material---------------------------.--_-_____-. ❑ Size: Diameter--------------------------------------Depth------------------------------ ---------------------Liquid Capacity----- ....------------------gals. Privy: Distance from nearest well-______________________________--- -------------Distance from nearest building------------------------------------------ Distance __________--.-.---____________.___-.--- Distanceto nearest lot line-----------------------------------------------------------------------------•--•------------------------•-----------.... ------------------ i Remodeling and/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, State laws, and rules and regulations of the San Joaquin Local Health District. t 4. .�.. (Signed)--------ft s '�'�' �� --------------------------- ----------------------------- (Owner end%or:,C�a�ntractorl 'By:_--------------------------------------------------------------------------------------------------------------------------------(Title)------------------ ---=------------:•.•'- - -------------- F (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY IAPPLICATION ACCEPTED BY------ ------------------------------------- DATE------ ----------- ----------- 1------------- REVIEWED BY + ----------- DATE__ BUILDINGPERMIT ISSUED-----------------------------------------------------------------•-------------------------- -------- DATE------------------------------------------------------------- Alterationsand/or recommendations----------- --------------------------- -------- ------•----------------------------------•------------•---------••-----------------••--------------------._._.. ---------•----------- ------------------------------•----------------------•--------- ----------------------------------------------------------------------------------------- -----------------•--------• ---------------------------------------------._.------------------ - i ------ FINAL INSPECTION BY: «' - Date �' �� -C _. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California 5 E9-9 REVIBEO B•59 r.F.CO.2M 6.60