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FUKUFFICE USE: ----------- ---------------------------- --------- --- APPLICATION FOR SANITATION PERMIT Permit No. . _�-----'_-. ----- -- --------------- ------------ ---------------- (Complete in Duplicate) - -------------- This Permit Expires 1 Year From Date Issued Date Issued ____ __ _.__6S 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 010dinonce„No. 549. ------------------------- JOB ADDRESS AND LOCATION... v_, '- �� 013- �cFD�2S F Owners Name ey, E? •'-- `_-F-/ -- -/-L---Y--�-'- i ------------- -- ---- - Phone---_------------------•----------- ----Address 1 - - , - Contractor's Name------- -46�:- --- ---------------------- -------------------- --------------------------------------------- Phone----------------------------------- Installation will serve: Residence P] Apa4r ment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ I Number of living units: -_.I.___ Number of bedrooms U�__---- Number of baths _}k Lot size -----------------------__________________ Water Supply: Public system ❑ Community system ❑ Private M Depth to Water Table _ _b ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam k] 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--------------------Material.------------------------------------ _____-_-_ -- ❑ No. of compartments___ _ _----------------_Size--------------------------------Liquid depth--------------------------Capacity Disposal Field: Distance from nearest well_�2-�_--------Distance from foundation_-__-;- b_--_____.Distance to nearest lot line___-2--0_______ Number of lines--------I-------------------------Length of each line____ 679 Width of trench ------------------- Type _.___----------__Type of filter materiall`.._.91_1_1 �____Depth of filter material___..I_Q__"_.__..___Total length_.E�-----_---_____________________ Seepage Pit: Distance to nearest well------------_---------Distance from foundation--------------------Distance to nearest lot line--____.._._____._ ❑ Number of pits-------------- - - --Lining material----- .....__.------- Size: Diameter--------------.-_------Dept h_..------------------------------ 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)-------------- ----------------------------------------------------------------------...---------•--------------••---------------------------------------- -------------•---•-•------------------•--- -------------------------------•----------------------------------------------------------------------------------------------------------------------------------------------- -------- --------------------- ------------------------------•------------------------------------------------------------------------------------------------------------------------------------------------- 'Q -------------------------- ------------------------------------------------------------ ------------------------------------------------------------------ --- ------------------------------------------------ ---- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, tate laws, and rules and regulations of the San Joaquin Local Health District. R - - ctor)(Si ned} t---------- ----- - (Owner and/or Contr By:------------------------------- -------------------------------------------------------------------------------------------------(Title)-------------------------------- ------- ---- --------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). y �L FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-/t/" - ------------------------ DATE---?----/�- -- 1� - - ---- REVIEWEDBY----------------------------------------------- --------- --- ------------ ---------------------- ----------- ------ DATE---- - -- BUILDINGPERMIT ISSUED------------------------------------------- ------------------------------------- ------------------ DATE------------------ ---------------------- Alterations and/or recommendations-------- ------ ---- -------------------------- ------------------------------------------------------------------------------------------------------------- ----------------- ------------------- - ---- ---------•------------------------------------- --- ------- ------------------------------------------------------------------------------- ------------------------ ----------------------------------...... -----------------------------------------------.-..-.._....-----. ------------:-- ----------------------------------------------- --------- --------------------- -------- ------------------ --------------- FINAL INSPECTION BY:_�i1_-F x y'G i - - -----•--- --- ------ - Date-1-- ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 4th Street Stockton,California Lodi,California Manteca, California Tracy,California F.P.r O.