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I-OR C)FFICE USE: _72 --------------- --------------------------------------- - --------__________________-_..___.._._-----._.______ APPLICATION FOR SANITATION PERMIT Permit No. ._= _ _a. � --------------- ----------------------------- (Complete in Duplicate) This Permit Expires 1 Year From Date Issued Date Issued k 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. JOB ADDRESS i AT! -- -- _-glzl _-- Owner's Name.r f Lr � R o �T __ ne � Gf Address--------------- _ - t Contractor's Name----------------- -- / " lC �� ----- --- -- ------L-Phone.._-_. .._._sem..•.__ Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trail ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths ______._ o ie P2 cz Water Supply: Public system [�C' ommunity system ❑ Private ❑ Depth to Water Table,5z>ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel [] Sandy Loam ❑ Clay Loam E] Clay ❑ Adobe�ardpan El Previous Application Made: (If yes,date____________________) No ❑ New Construction: Yes ❑ No �HA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) tic k: Distance from nearest well-----------------Distance from foundation------------------- Material----------- _-__-_..__-----------------.--------- x No. of compartments.. ----------Size------------------------•--- ---Liquid depth------------------------- Capacity------------__........ 1 f : ODm2posal d: Distance from nearest well � Distance from foundation.- _-�,�- Distance to nearest lot line_ ---------- Number _--____. Number of lines-__.__---. Length of each line______________ � � --- -- g ��.`-----.Width of trench - - -- -- - -----�------ Type of filter material.,�r / Depth of filter material -,/ length___________________ ----------- Seepage _____ __Seepage Distance to nearest well- -_ __ DistanI � fo .d_ ation _ _ __ is+ nc to nearest lot line____a__ SizNumber of pits--e__ � _.________ Lining materiaa: Diameter._ Deptn_.(:::2,,_ ____?_______ OG 4 Cesspool: Distance from nearest well-----------------Distance from foundation_______.------------ Lining material------------------------------------ ❑ Size: Diameter_ Depth ------- -----------------------------Liquid Capacity----------------------------gals. �j ! Privy: Distance from nearest well__________________________-----.--___----___..Distance from nearest building-----------------------------_----_------ . [ i ElDistance to nearest lot line-- ------------------------------------------------------------------- ------------------------------------ Remodeling and/or repairing (describe):--------------------------------- ----- _------------ I ----------------------------------------------------------- ----------------------------------- -- --------------- ---------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared is application and t a+ the work will be done in accordance with San Joaquin County ordinances, a e laws and rules a re u tions of the San J quin Local a Health District. ----(Signed). (O er and/or Contractor) By:---------------------------- ------- --------- - ----------- - ---------------- - -----(Title-- - ---------- -- --- -- (Plot plan, showing size of lot, location of sys+em in relation o wells, buildings, etc., can be placed on reverse side). 1 • FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--.----- ---- ------- ------------------------------ DATE-------------- REVIEWEDBY------------------------------------ r -------- ---------------------------------------------------------- DATE-------- .................. BUILDING t BUILDING PERMIT ISSUED----------------I--------- ------------------------------------------------------------------------- DATE. Altera ions and/or recommendations-' _________ _ ---------- ---------- ----------- -------------------- --------------------- ` - t } --------------------- ---------------------------------------------------------------- ------------------------------- --'---------------------------- ------------------------------------- ---- r ---------------------------------.---------- ------------ ------------ ............. ----- --- FINAL INSPECTION BY —e�.r- --- -- ---------------- 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.P.C 0. l F,,