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t rUK UrrlLt USt: ----- -------------------- - G APPLICATION FOR SANITATION PERMIT Permit No. ___.�--/1---------- ------------------------ ---------------------- ---_..._ (Complete in Duplicate) :(11 --------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date issued F Application is hereby made to the San Joaquin Local Health District for a permit to construct and install th r herein des n ed. -- This application is made in compliance with County Ordinance No. 549. ' JOB ADDRESS AND LOCATION,�O,6f 4,__rr/f_�f�Y rL' // r . Owner's Name---- /_�f'ff-/fes_ +t1,rr Phone - Address---------1�"- •[_r'_ A�/? �le ----------------------------------------------------------------- --------------------------•------------•----- Confractor's Name----------- -- � ---------------- ----------------------------- ------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court E] Motel ❑ E]Other Number of living units: _ __ Number of bedrooms Number of baths !___._ Lot size -_________________________________ r Water Supply: Public system ❑ Community system ❑ Private Z? 5epth to Water Table 0V {t. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam kl,08y ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date---------------------I No P", New Construction: Yes j?"INo ❑ FHA/VA: YesiA- No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: i (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic 1 Septic Ta Distance from nearest w II4,4_j __Distance from f u dafion_lC _______-.Mat ial_ ' _ ,r_ e= / - No. of comparfinents�_____- ------- S1-__ i quid depth---- ____ - CapacifyX�. �____ v� r Disposal Field: Distance from nearest well Distance from foundat'o/n�� -----------Distance to nearest lomat line- ____-__-` Number of lines__�_____- __ _-______Length of each lme_V717-____- Width of trench _ __ -___------------------ Type of filter material� Q Depth of filter material_ __________Total length__. __ -______________________ Seepage Pit: Distance to nearest well---------------------Distance from, fotmdation--------------------Distance to nearest lot ' - line_-_-_______._-.._ ❑ Number of Pits-----_----__---------Lining material Diameter --------------------------- Cesspool: � Distance from nearest well__--------------Distance from foundation--------------------Lining material_____-_-___.__--____________________. ❑ Size: Diameter--------------------------------------Depth------------------------------------------ --------Liquid Capacity----------------------------gals. Privy: Distance from'-Barest well_-.-___-------------------------------------- Disiance from nearest building.____________________________________-_ ❑ Distance to nearest lot line-------------------------------------------------------------------------- ------------------ ----------------------------------------------- PO �... . . Remodeling and/or repairing (describe)___________ __ .f� ___ -------------------------------------------------------- i -------------------------------------------7---------------------------------------------------------- - ----------------------------------------------------- —— ------------------ ---------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------- ----- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I here6y certify that I have prepared fhis.-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. j (Signed)-------------------------`}/ - ----------- By: -------� Contractor) - g ------------------------------------------------------------------------------------- /,�� (Title (Plot plan, showing size of ]of, location of system in relatio wells, buildings, etc., can be placed on reverse side). F D A ENT USE ONLY APPLICATION ACCEPTED BY-----------------------------=-I- ---- ------------------------------------------------------ -------------------- ----- DATE- ----------------------- --------------- ---------------- REVIEWED BY-- ---------------------------------------------- - DATE r-/` — - BUILDINGPERMIT ISSUED--------------------------------------------------------------—--------------------- .-- DATE------! /----------------------------------------------- r-, Alterations and/or recommendations-------- -- ----------= -------------------------------------------------------------------------------------------------------------------------- 1` ------------- -- -------------------------------------------------------------------------------- ------ ------------------------------------------------------------------------------------------------------ c.- --------------------------------------------------------------------- -- --------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------- ---- -- - -- -------- -- ---------- ----- ------------------------------------------------------------------------------------------------------------------ * FINAL INSPECTION BY:_----- -------------- Date-- - -- ------------------ - - —---------------- ------------------------ - SAN-JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazeflon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street