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FOR OFFICE USE: -------1 -A--------- - --- APPLICATION FOR SANITATION PERMIT Permit No. ------------------------------------------------I-------- (Complete in Duplicate) _ This Permit Expires 1 Year From Date Issued Date Issued Applica#ion 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. &2-6 E _ SIE C716/%) �"W- JOB ADDRESS AND LOCATION---� • O r(3 �dL -'= .` � ----------- Owner's •-----Owner's Name----- ---------------------- ------------------------------------ ------------------------------------------ -- Phone---------•---•------------------- Address---------- Y. 13----S1-----------_----_ ----------------------------------•-----------------------------------...------------------------•------------------------------- Contractor's Name-----------------------------------------------•-------------------------•------------------------------------•-•----------------..-•------- `-- Installation will serve: Residence [A Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---I--- Number of bedrooms --- Number of baths .1----- Lot size ----,-- _-_ _.._L,3_ _ --------------........ Water Supply: Public system ® Community system b Private ❑ Depth to Water Table -------- ft. 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 ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation----/�2. .........Material_--.--_ ------_-- No. of compartment s------_ .-%Ir--------- -`------Liquid depth....... ------.Capaci#y.__�' Disposal Field: Distance from nearest well- from foundation --/0_'........Disjo ce to nearest lot line--�-- ---_- .fh Number of lines-------------y________-----------Length of each line-.74,C:'_. s`.i!3.:` idth of trench.---__.�,_.:-_-___-_------_---_-- Type of filter material___ ____--Depth of filter material----1- ------------Total length-------- --------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation---....__--_____-_..Distance to nearest lot line--._---------_--- � ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation-------------------- Lining material------------------------------------- ❑ Size: Diameter--------------------------------------Depth--------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well___----------------------------------------------Distance from nearest building-------_-------_-._-__--•___---_----_-.-. ❑ Distance to nearest lot line-----------------------------------------------------------------------------------------•---------------------------------------------------- Remodelingand/or repairing (describe):---------------------------------------------------------------------••-•----------•----•---------------------------•---•------------------------•-•----- ' --------------------- ---------------------------------------------•--•--- ------------------------------•-----------------------------------------------------------------------•--------------------------- ount-- I hereby certify that I have prepared this application and that the work will be done in accordance with San JoaquinC y ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. f � . (Signed)---- % u 4 --- ------•----------------------------------------------------------------------------------(Owner and/or Contractor) 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 APPLICATION ACCEPTED BY----- --------------------------------------------------- DATE----- ------------------------------------------------------ REVIEWEDBY------------------------------- -------------------------------------------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------- ----------------------------- ----------------------- Alterationsand/or recommendations: --------- ------------------------------......------------------------------------------•------------------------------------------------------------- - -----------------------------------------------------------•--------------------------------------------------------•-•----------------------•-------------------•--•-- ---•------------------------------------------------- Date.-- -------------- FINAL INSPECTION BY:..--r; ._69y",----- ---=�-`-�-- ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 105 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES-9 REVI®EC 0.59 F.P.Cn.2M 6.60