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FOR OFFICE USE: 4 -41W s- ------------------------%�..3.ej /�i7 --------------------------------------------- 6 APPLICATION FOR SANITATION PERMIT Permit No. C.!'._-_/ ... _!- ! T i ----- ----------------------------------------- - {Complete in Duplicate} r3/3 5 .--.___._ 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 N9. /� � j JOBADDRESS AND LOCATION--,..--. _: _..__ .--,(P--- -- ------------------------------------------------------------------------------------------------ - Owner's Name__ f Phone. %Z4,4 Address ---- --'---• v Contractor's Name �' ��`�' ` I -----`----------------------------------------- Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel p Other ❑ Number of livingunits: - __ - Number of baths _� �__ Number of bedrooms .___ Lot size _ �_�_�,r�______________________________ f01 Water Supply: Public system Community system ElPrivate F-1Depth to Water Tablet ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobelardpan ❑ Previous Application Made: (If yes,date----------__--------I No 9' New Construction: Yes ❑ No FHA/VA: Yes ❑ No R;�— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sep is T36k� Distance from nearest well_________________Distance from foundation-------------------Material------------------------------------------------- ft$' No. of compartments---------- ---------------Size--------------------------------Liquid depth-------------------------Capacity----------------------- Dis�posal F•el): Distance from nearest well.................Distance from foundation--------------------Distance to nearest lot line________._- Number of lines-----------------------------------Length of each line-------------------- - ------Width of trench------------------_--------------.- Type of filter material-------------------------Depth of filter material-----------------------Total length____________-.___--_-______._________.- Seepage Pit: Distance to nearest well___^^-----------Distance frgirn foundation---19.: ...--.Distance to nearest lot iine_AW_______ Number of pits___.f______________Lining material _. ._ / ----Size: Diameter._,?.__.__..____Depth_ l_ oe------- I/ Cesspool: Distance from nearest well__---------------Distance from foundation....................Lining material--------------.---------------------- S ❑ Size: Diameter------- ------------------------------Depth_-------------------------------------------------Liquid Capacity----------------------------gals. W Privy: Distance from nearest well------------------- -----------------------------Distance from nearest building--------------------------------._.__--._. ❑ Distance to nearest lot lire---------------------------------------------- ----------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe)---------------- ---- >i ----- ------------------------- ---•----------------------------------------------------------------------•---------------------------------------------------------- --------------------------------- -------------------------------- -- ----------r--------------------------- ---------------------•---------------------------------------------------------------------------------------------------------------------------------------------------------------- ------- ----------------------------- -- -------------- -----------------------------------•-••------------------------------------------------------------------------------------------------------ I hereby certify that 1 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 Contractor) By:--------------------- - ---------------------------------- --- f------(Title)--- �- ' --------- (Plot plan, showing size of lot, location of system in relatio o wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------- • ----------- --------------------- ------------------ DATE------ ' =- -- 'f REVIEWEDBY--------------- ---------------------------- ------------------------------------- DATE BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ Altertions and/or rec m nd ions: ----------------------------------------•----•----------------------------------------------------------------------------------------------- ------ !�-��---- �'"-�--- d - ------------------------------------------------------- FINAL INSPECTION BY:_ ------------------------ ---------- ---------- bate. �7�-'�---fes- ------------------------------------------------------- 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.