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FOR OFFICE USE: b -- ----- Permit No. .4W.1.. APPLICATION FOR SANITATION PERMIT ----------------------------------- (Complete in Duplicate) ----------------------------------- --------------------- This Permit Expires 1 Year From Date Issued 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. B ADDRESS AND LOCATION. -- ------ JO Owner's Name--- ---- - ------ • -- ------------•--- ---- --•--------------------------- ----------------- Phone------------------------------------ Address - - ------- ------------------ ----------------------------------------•----------------------------------------------------------------------------------- Contractor's Name------------- - 7.'2 - - -------------------------------------------•-----------------------•--------•---- Phone................................... Installation will serve: Residence ayo'7�partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/-_ Number of bedrooms a- Number of baths _/--- Lot size �7-g 9�-��--------------- Water Supply: Public system Community system [IPrivate ❑ Depth to Water Table � t.$ 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 ❑ No Rg�FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tnk-- Distance from nearest well-----------------Distance from foundation--------------------Material-----------------------------------------.------- �r� No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity-•----------•-------••- i Disposal Fi d Distance from nearest well--�,Q__.-----Distance from foundation-_&A0---------Distance to nearest lot line---7r---__--_-_-- �sl Number of lines__..___.1`...-f.... ______. ength of each line____14�,44, 7--- �„--.Width of trench__ .-_`_________________..... 00 Type of filter material s/ -_:Depth of filter material ---Total length---- -- -- f - - Seepage Pit: Distance to nearest well-_--,/ -__Distance fr foundation__�f.�_-----_-.Dist n40 to nearest lot Iter- ._-------- w Number of pits------__---_-_--_-.Lining material-__ __ ---------- /" ,��,�,e�Size: Diameter._ Depth_X'�-.----------------___.__ S Cesspool: Distance from nearest well-----------------Distance from foundation---------.--------- Lining material-------------------------------------- N ❑ Size: Diameter•---- ------------------------------Depth-----------------------•----------------------------Liquid Capacity--------------------........gals. . Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-------.-----------------------------.-.-. V ❑ Distance to nearest lot line------------- �-------------------------- ------------------------------------------------- a Remodeling and/or repairing (describe):------------------ ---------------------- 11510 -------------------------------------------------------------------------------- ------------------------------------------------------------------ ----- ----- ro ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------- 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 apo regulations of the Spin Joaquin Local Health District. (Signed)------------ or Contractor) ---------------- ---- - -- ----------- -- -- By: ------ ------------------------------------------------------------- --- - - -----(Title)---�ti �f�=� - (Plot plan, showing size of lot, location of system in relat' o wells, buildings, etc., can be placed on reverse side). FOR KEPARTMENT USE ON Y APPLICATION ACCEPTED BY--------------- ------ -------------------- ------ �� DATE------- REVIEWEDBY--------------------------------------------- - --------------- ---------------------------------- ---------- DATE BUILDINGPERMIT ISSUED---------------------------------------------------------------=-------------------------------------- DATE.----------------------------------------------------------- -------- z ' ------- === --'�=-—------------------- ------------------------------ Alterations and/or recommendations:------ � ----------- ----------------------------------------------------------------------- -------------- ------ ------- ------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------- - ---------------- ------- --------------------------------------------------------------- --------------------- ------ ----------------------------------------.. . FINALINSPECTION BY-------------` 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.CO.