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FOR OFFICE USE: -------------------------- ------- - - -- -------- k:- _�. APPLICATION FOR SANITATION PERMIT Permit No. ..l_ _ - ---------� ------------�/- - /-F (Complete in Duplicate) !o /a �_....--��:...�� _ ...�� . _ Date Issued _ . Th'rs'Permif Expires T Year From 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. JOB ADDRESS-AND LOCATION--------- ------- � _/l'!�( - `-- ------------ M Owner's Name. - I�- __._.._ _ Phone--•--••----= I ----- ------ - --- ------ -- ------------- -- Address-------------------------f- ---------- --------- ..._.- ----- - ---- -- ------ ----- --------- -- ----------------------------------------- ------------------- Contractor's Name-------------------------------------- -- ----- ----`----------------------------------------------------------------------------------- Phone............_----------------- Installation will serve: Residence K Apartmen House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I___ Number of bedrooms _c-__ Number of baths _-l__ Lot size ...... _ ___________ � Water Supply: Public system ❑ Community system ❑ Private M Depth to Wafer Table ._`1&,fts;, Character of soil to a depth of 3 feet: `Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe,g. Hardpan ❑ Previous Application Made: (If yes,date____________________) No ❑ New Construction: Yes E No ❑ PHA/VA: YesV No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: Y (No septic tan or cesspool permitted iPu is fwer is available within 200 feet.) Septic Tank- Distance from nearest well_/_0_0_ Distance from found ion_:_lp__ ________.Material_______ - -- - L No. of compartments----------- ----------Size----q- - - .-. __.Liquid depth---------- -- - -- ----Capacity---- __ Disposal Field: Distance from nearest well L00 _Distance from foundation...--�0---___-Dis ante to nearest lot-line.___-.. •, Number of lines 1 / __ Length _ vtt of each line_____ ________ Width of.trench.= . .,P::---____F_____.__ Q Type of filter matecialS•. _G_ ___Depth of filter material------- �'--._._Total length_........ C?_ __ ___________'___ .. 1A Seepage Pit: Distance to nearest well---------------------- fromllfouncla#ion:-----------------..Distance to"nearest lot line_____-__.___.---- ❑ Number of pits-------°--------------Lining material-----------------------Size: Diameter----------------------.Depth---`.- - ----F-•.-------`.-- ' 1 Cesspool: Distance from nearest well------------------Distance from foundationLining materia:_________.___.___. .____...________.____._________._.. ❑ Capacity-_--: j Size: Diameter--------------------------------------Depth--------------------------------------------------._Liquid Capacity-_-'-----------------....gals. Privy:, Distance from nearest well-_._________________________________--____._.._Distance from nearest building----------------------------------------- ❑ -------------------------- ' Dis#ante to nearest lot line------------- - -- •--------.------------------------------------------------------------------------•-----=------------- µ. r Remodeling and/or repairing (describe) ---•-------••----------------------------------- ; r ----------------------•------• ------------------------------------•--•----------------------•--------------•-------•---- --------------------------------------------------------------------------------------------------- 1,hereby certify that 1-have prepared this application and that the work will-be done in accordance with San Joaquin County ordinances, Sta�e to , and rules and regulations of the-San Joaquin Local Health District. <`t __ZM ------------------------------------------------------------------------- ---(Owner and/or Contractor] By:------------------------- ---------------------------------------=-----=--------------------------------------------------•----(Title)----------------------------------------- (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEP RTMENT USE ONLY - - -------------------- DATE-- ---------------------------------- REVIEWED ACCEPTED BY--�' ---- -- --- - ----------------------- --=- ------------------ - REVIEWED BY. - ------------------------ DATE --------------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------- Altertion and/or recommendations------------------------------ ------------ - ----------------------------------------------------------------------------------•------------------------------- / S� T __ FINAL INSPECTIONBY::....... ' -------- - - - Da#e-..: � -1`------------------------------------------ SAN JOAQUIN LOCAL HEALTH-DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stocktonr California Lodi,California- Manteca,California Tracy,California k E9.9 REVISED e•69 F.F.CC.2M 6•50 i