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FOR OFFICE USE:: p y ------ --- - r:6-1------ ------------------ ----------------------------- ------------ --------------------------------------- ------ APPLICATION FOR SANITATION PERMIT Permit No. ------- -------- ---- ---- -- (Complete in Duplicate) Date Issued -------------------------------------------- This Permit Expires i Year From Date Issued T" 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. 7_ Sop_ 2fo�t a r k t tSc e4'� 3 JOB ADDRESS AND LOCATI N_�' �5 L'!' f__�n w- ,��•' �-* I - ------------ Owners Name �1 J` � .. ------------------------------------------------------- Phone-- -------- S Address----------------------------------- - -- Contractor's Name--------- - ..... .... _ - -�'`.- -•---•-------------------------------- --------Installation will will serve: Residence )I M�partment House ❑ Commercial E] Trailer Court E] Motel [:] Other ❑ Number of living units: -_`___ Number of bedrooms _Number of baths __!--__ Lot size -_ff___``-4114 _ ________________________ Water Supply: Public system ❑ Community system ❑ Private �epth to Water Table 4 -- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2---H- ardpan ❑ Previous Application Made: (If yes,date--------------------) No New Construction: Yes E N' ❑ FHA/VA: Yes ❑ No Or TYPE OF INSTALLATION AND SPECIFICATIONS: ^ (No septic tank or cesspool permitted if public sewer is available within 200 , _Liquid feet.) / Septic Distance from nearest well___ __ DistanFefromfound90on__..-- --Material_ -_ _______ _______I__ _____________ No. of compartments__-__� ------------Size�^f�kSX.� de th----. �'t[ -___Capacity... ---- -----r�Q1 f" Disposal Field: Distance from nearest well .1i� Distance from foundation___ D.y..---.Distance to nearest lot line-__—_____ Number of lines---------------,-��--I_---j- Length of each line--------------5----------Width of trench.-------------- -------------- �Q Type of filter material__/ `__Depth of filter material______ _Total length -- lengt#________________YS_��_____-_.__._ Seepag tDistance to nearest well_ 'I'M--------Distance f m f undafon___.74_/__.Distance to nearest lot line----!__-____ f�E Number of pits----! --------------Lining material_ _-Size: Diameter__ �.6_ ..___ � Depth_. ------ap-1-S-------._-___.__ Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material--------------------------_-________El . Size: Diamefer--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals . C Privy: Distance from nearest well____________________________________--------------Distance frorri nearest building------------------------------- _____.._. ❑ Distance to nearest lot line----------------------------------------------------------------------- --------------------- ----------------------------- Remodeling and/or repairing (describe)----- - ---•- ----------------------------------------- - ---------------------------------- ------ ------ --------------7 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------•------------------------------------------------------------------------------------------------------------------------------ I hereby certify that [-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. (Signed)-- ---••.A-- --- ----7- ----- ------------------------ `- -----------------------------------------------------------------------...(Owner and/or Contractor) $y---------------•-----•---•------••------•---------------------------------------------- ---------------------------------------------(Title)-------------------- -- ---- --- - ---- (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 11 APPLICATION ACCEPTED BY - DATE-------- ZZ --------------------------- REVIEWEDBY--------------------------------------------- -------- ----------------------------------------------------------- DATE------------- ---- -- - -- ------------------------------- BUILDING PERMIT ISSUED-----------------------------------------------------------------------------------------------------• DATE--------------------------- --------------------------------- Alterations and/or recommendations:-----------------------------_----------------------------------------------------------------------------------------------------------••------------------- ---------------- --------------------------------------------------------------------------- ----------------------- -------- --- -------------------------------------------------------•---------- --'------------------------------------------------------------------------------------------------------------------------------- ------------------------ FINAL INSPECTION BY: L`.'__C^c_t------------------------------------------ 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 cs 9 neviSso 8-59 3?A 3-63 i.P.CG.