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FOROFFICE USE: ------------------=------------------------------------- ----------------------------------------------- APPLICATION FOR-SANITATION PERMIT Permit No. ,5Z. .1d ._ -------------------------------------------------------- (Complete in Duplicate) This Permit Expires i 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. F . JOB ADDRESS AND LOCATION-_/ �---------------------------------------------•--------------•----------------•--------•-••---- F .�. - � --- ---------------------------------------------' Owner's Name------ --� - --- ----------------- -------- � Phone----•• --.....-- •---.....-•-------- - Address----------f>�� •�1 P-r :.......- Contractor's Name f�,t � C " = """------ -`------------------------- Phone. -------------- Installation will serve: Residence �Apartment House ❑ Commercial ❑, nTrailer Court ❑ Motel ❑ Other ❑ Number of living units. /_-Number of bedrooms _ ._ Number of baths /-_._ Lot size ------------------------------------- Water Supply: Public system ZrZommunity system ❑ Private ❑ Depth to Water Table 0$'ft. Character of soil to a depth.of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date....................) No Rf'New Construction: Yes'❑ No R3-- FHA/VA: Yes ❑ No �- TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Taplj: Distance from nearest well-----------------Distance from foundation--------------------Material------.------------------------------------------ F40 9 ________--_-..._---._---.-.___.-_-.F4'9*-OV No. of compartments- ------------------------Size--------------------------------Liquid depth--------------------------Capacity------- ---•-------- i Disposal Field: Distance from nearest well----- •=__..._Distance from foundation----zle-_----_Distance to nearest lot linef ---.----- Number of lines-------_l___ ____________ Length of each line-----�O--'_ ._-__Width of trench__r _-_,____-____._..-___--- . j Type of filter materiai_��;6l �Depth of filter material--- ------Total length__ A------------------------------- Seepage Pit: Distance to nearest well-_____________--------Distance from four daticn__� _---__.Distance to nearest lot line►$ _--______ J 1 Number of its_..._ ___ " ` . Linin mate ria l___��er�-;,Size: Diameter_ Cesspool: Distance from nearest well----------------- from foundation_ ----------------- Lining material------------------------------ Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity----------------------------gals. r Privy: Distance from nearest well-------.-----------------------..................Distance from nearest building----------------___------:.___.__..__..._r ❑ Distance to nearest lot line------------------- --------------------- ----------------------------------------------------------- ----------------------------------- y ! n Remodeling and/or repairing (describe_________________ ----------------- -----------------------------------------------------------------------•---------------- --------------------------------------------------------------------------------------------------------------------- - - - - - -- - ------------ - - -- -- - /- - --------- - ----------------------- ------------- .�.��c ----- 'a-` d I hereby certify that 1 have prepared this application and that the work wl I be done in accordance with San Joaquin County j . ordinances, State laws, and rules andregulationsof the San Joaquin Local Health District. 9 ,Q�/ - �� r- ------------ ---- ` ( ) 4 (Signed)--------•---- ------. {`� r Contractor l By-------------------------------------------------••--• ------ --- - - t- -----{Title) /Z ---------- (Plot plan, showing size of lot, location of.system in relat' to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- ------------------ -06-;2_V------------------------------------------------- DATE------ ! REVIEWEDBY-------------------------- ------------- --- --------- --- ------------------ ---------- --------------------------------- DATE---------------------- BUILDING PERMIT ISSUED------------------ ------.-----._ DATE--------------------------------------- --------------------- Alterations and/or recommendations:._ l -�e _ ----------------------------------------- -------------- -------------- r -------------- - ------------------------------------------- ------- --------------------------------------------------------------------------------------------------------------------------------------- -, ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 71� 1=1NAL INSPECTION BY: ------------•-------- Date. - ............... ------------------ ---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1801 F.Hazeiton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy, California r F.p.CC. 1