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FOR OFFICE USE: -+ra (� 44 ----------------- ---- _._ ¢ �,. - ,;,�a.P'�;,..� i` k rt s�t : — APPLICATION FOR:SANITATION PER .Permi+ No. .:. -5- � - ' l ---------- '___-- ------------------- (Complete in Duplicate} Date Issued /1 --------------- -------__._-- 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. 549. �� ------ JOB ADDRESS A LOCATION------------- --------------------------------- - Phone Owners Name---- -- -----•--------------- - //// Address----- --------- '"7 If ----- -• - % �.. Contractor's Name = •------------- Phone—--'.....-_ ----- ----•._. Installation will serve: Residence Apartment-House E]'-Commercial ❑ Trailer Court ❑ Motel r] Other ❑ Number of living units: __/__ Number of bedrooms 0.. Number,of baths -/--.Lot size,___ ---- _- -- -------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table 24_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel [ISandy Loam [IClay Loam [:1Clay [J. Adobe Hardpan El Previous Application Made: (if yes,date..__.--_-----------1 No E] New Construction: Yes No E] FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: i (No septic tank or cesspool permitted if public sewer is available within 200 feet.) i Septic Tank: Distance from nearest well __ 4__Distance from foundation -4__._.__--4 Materipi___. _) _____________"_.____ _.._...______. __Li uid de th-----'�---------------Capacity__-- ¢ ' No. of compartments__--____�~__.___-Size_ S_ _ _ q p. i w,w . Disposal Field: Distance.from nearest wel/0Q_..._Distance from foundation _. �-_._____.Distance to nearest lot line_________________ Number of line --- .. __ Length of each line_�_S____� __._.Width of trench_-__! __�_________________ r Type.of filter materialS.t_y _[1 C_ _Depth of filter material_JA?__.-________Total length__ 4V._____________--"______ j Seepage Pit: Distance to nearest welldQ--- Dista e fr m_ tion , _.____..Distance to nearest lot --------De th-- �- /j��' Number of pits.-- ------------Lining mater al- _ - -:__--- ize: Diameter __- p ►- Cesspool. Distance from -nearest well------------- ---Dist ce f o ndation:_=------------------Lining material___.__._______.___,.___________--__-- Q ' I } ❑ Size: Diameter-------------------------------------- ---------•--------- � Liquid Capacity gals. P-rivy: Distance from nearest wet!_____________________________ 1. ____ ------Distance from nearest building_=_-_____._----__________---.----.--- -. ❑ Distance to nearest lot line----------------------------- ------ --------------------------------------------------•------- Remodeling and/or repairing (describe)----------------------- ------------•---- }---------3 ...-----------------•---------------------------------------------------- 3 F #------"------------------------------------------------------------------------ -------- •----------------• -------- ------------------------------------------------------------------- t -------------------------------------------------------------- ----------------------------•=-------------•-------------'----- --------•-------- --- = ------------------------- - -------------------•-------•----------------------------•---------•-----------------------------•-•------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S e laws, and rules and reulations of the San Joaquin Local Health.,District. i � ! Si ned (Owner and/or Contractors 7- (Signed)--} F BY: -= - --------- --- == (7i+le} r (Piot plan, showing size of lot, location of system in relation to wells;: tjildings, etc., can be placed on reverse side). l e FOR DEPARTME U E ONLY i Z DATE "(—=�Cf --- -------- APPLICATION ACCEPTED BY-------- ----------------- -- ------------------- REVIEWEDBY--------------------------------------------- ---------------------------------- ------------------•------------------------- DATE---------------------------------------------- ------------ - BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------`----------- --------- DATE--------------------------- -------------------------------- Alterations and/o re m en ations' `' ----------------------•- ---------------------------•------------------------- �p `s �~� = ' Jr ----------- ----•-------------------------- --------------------------------------------------------------------•---------- --------------------------------- X,--r -- - -- ------ FINAL INSPECTION BY:_._--- C__: 4.i-Com"'------------- -------------------- Date-___ - ------ ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED S-59 3M 3-'S3 F.P.CO.