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--------- -- r x �rric.t USE: Z ------------------ --- / y vv- APPLICATION FOR''SANITATION PERMIT Permit No. ..._!... p. ._� ------------ ------'1 ------ (Complete in Duplicate) 1 -- - --------- This Permit Expires i Year From bate 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. 5 JOB ADDRESS AND LOCATION... -------------------------------------------------------------------------- Owner's Name---------------------------------- /4e49 /` ---------- ----- -- Phone------------------------------------ Address ! _ �f��CP �yL� -----------------------------------------------------.---------------------------------------- Contractor's Name------ < `�-------- al ---------------- •---------- ----------------------------------- Phone---------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [] Other ❑ Number of living units: ___I___ Number of bedrooms ___,� Number of baths _--___ Lot size ---6..o--x------ ___________________ Water Supply: Public system �ommunity system ❑ Private ❑ Depth to Water Table -A6ft- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sand Loam ❑ Clay Loam ❑ Cl� Ad`VA: y ❑ Ao ardpan El Previous Application Made: (if yes,date-----------------_-I No New Construction `Yes ❑ No Yes ❑ No 's 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------------_-------Material ❑ No. of compartments--------------------------Size------•------------------------Liquid,dep*h--------------------------Capacity------------------------ Disposal Field: Distance from nearest well ------Distance from foundation---lh__l......Distance to nearest lot upmber of lines--------- of each line__��_�._-___-/ Width of trench_- W11 N T e of filter material-___ Y �-'Depth of filter material------ __-Total length----:;�-�________ ________________- 5eepaa Distance to neares well___�r-----Distance from foundation-/42..I......Distance to nearest lot Number of pits_____ ________________Lining material _-/A-.4. ___.Size: Diameter.3,3__.-___!�__-.Depth-_S � --� l� 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___-__----------------------------------------- V ❑ Distance to nearest lot line------------------------- -----------------------•----- � 1� _ Remodeling and/or repairing {describe)--------------- ------- ----•'-'`-��91-�---•--- ------ - r�-� 11----��.-------•---------------- -------------------------------------------- C -------------------------------------------------------•-------------------------------------•--------------------------------------------------------------------------------•------------------------------------------J -- ---------------------------------------------------------- --------------------------------------------- ---------------------------------------------------------------------------------------------- I hereby cerft y th t I hfped this application and that the work will be done in accordance with San Joaquin County ordinances, Stat la , and 1 tions of the San Joaquin Local Health District. (5i ned � �-__--- - (Owner and/or Con actor) 9 ---- --- ------- By:-------------------- -------- - ----- -- ---- ---- --- - --------------------(Title)-- ---�-{�°�-"�---- ------------ (Plot plan, showing size afj of system in relation to wells, s, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- = --------------------------------------------------------•- DATE------- ----------------------------------------- REVIEWED BY-------------------------------- -------------------------------------------------I------------------------------------------ DATE------------------------------------ BUILDING PERMIT -ISSUED-------•--•------------------------------------•------------------------------- F-------------------- DATE Alterations a=/or recommenda�n •._.____ ------------------07------ 7 4-7-------- - ------------------- ------- ---------------------------------------------------------------------------------------------------------- ------------- a _ ------ -------- - 7 -------------- - -- ------- ,z.�-. FINAL INSPECTION BY------------ -- - L. - - Date ' - ------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave: k 300 West Oak Street 124 Sycamore Street 205 West 9th street Stockton,California' Lodi,California Manteca,California Tracy,California ES 9 REVISED S•99 3M 3-'63 F.P.CD.