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rFO,R OFFICE USE: ,/ ------------------ ------------------------_:_---------- APPLICATION FOR SANITATION PERMIT Permit No. .. _,�,!.1.... ------------------------------------------------------- (Complete in Duplicate) Date Issued ____!� --------------------------------------------------------- This Permit Expires 1 Year From' Date Issued ___-��-_�/�G__- , 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. i r JOB ADDRESS AND OCA I N ----- •------ Owner's Name-- :--�...-- Phone.................................... Address-.-----1[105`------ ---------------------------------------•-•-•----•••-•-•-----•-- Contractor's Name.-_S . ----•• ---••- ..... --------------------------------- ------•----------------____ Phone--------------- ............ Installation will serve: Residence [Er-Apartment House ❑ Commercial ❑' Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ...... Number of bedrooms __ .'_ Number of baths __�_,' Lot size ..__.5. 0 i .! .......... .......................... Water Supply: Public system Pjr Community system ❑private..❑_Depth to Water Table .1.6t. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑-. Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No New Construction: Yes �IQo�❑ FHA/VA: Yes [3 No I]�- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic k: Distance from nearest well!'h ._Distance from fou dation_�d_�_.___._..Mate� .. al.. __!- ................................r No. of compartments_______%L th______ __ -__________Size_______ 4 ,?_ _ -___Liquid dep ______________Capacity..... Disposal Field: Distance from nearest w ll_y- ------Distance from foundationj�______Distance to nearest 1pt line..s:�....... Number of lines__________ __7�------Length of each line_ _ _____________ ___________Width of trench.._.. -------------------- Type _.__ _____..___ Type of filter material-_.. - _L°-��i__-___Depth of filter material... r-�__---_---Total length..._... `..._9_5__---__ Seepage Pit: Distance to nearest well ______`_------------ Distance from foundation....................Distance to nearest lot line................. ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth----------------------•---------• Q Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_______________________________-_-_-_ 4, ❑ Size: Diameter-------------------------------------Depth--•-------•-----------------------------------------Liquid Capacity.-----_--•-----------....gals. \) , I Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ El Distance to nearest lot line.-------- --••---------------------- --•- •--- ----.......-•--- --------------------------------------------------------••---- 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. (Signed)-------------------------------------------------------------------- ----------------------------------------------------------------------------------(Owner and/or Contractorl By:---------------------------- ----........- (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 T APPLICATION ACCEPTED BY------------------------ --=------------ --------------- f Q ( ----- DATE------------ ------L_ ------------ REVIEWED- BY ``=== _ : . ' I --- ----------------------- DATE-------------------------------- ----------------____._. BUILDING PERMIT ISSUED. _' -- 1�---Li- - -------------------- DATE_-------------•------------------ - Aheralions and/or recommendations: / -----------------------•- - - -- ----------- c - ------- ------------ J ---------------------------------_............_-------- FINAL INSPECT -- - -------------------•- -- - ------ Date--------�.- �: ._-..-- _..._. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street - .. -... 300.West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California_s 9 Manteca,California 1 t `-3 Tracy,California i EB 9 REVIBEo a-69 PM 6-61 AILAB t