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^�vrc Urrrl,t U v —,3 -------------------------/Q_______- APPLICATION FOR SANITATION PERMIT Permit No. . - --------------------------------- ----------------------- (Complete in Duplicate) , t ---.- This Permit Ez ires 1 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. JOB ADDRESS AND CATION.f__'_.1 - _ Owner's Name__________ -- - - --Y--- � - -----------------------------------G - 7..?- --------- ------ ---- - -- Phone-----Address----------- --------- ---- - -------- - -------------•••-------------_-•- Contractor's Name______ 11 -- --------------- Phone_y � l�r ❑ ❑ Motel nsta lation will serve: Residence Apartment House ❑ Commercial Trailer Court ❑ Other ❑ Number of living units: .__--Number of bedrooms Number of baths __Z__ Lot size Water Supply: Public system ❑ Community. system [.Private ❑ Depth to Water Table ........ ft. 11 Character of soil to a depth of 3 feet: Sand [] Gravel ❑ Sandy Loam ❑ Clay Loam p Clay ❑ Adobe E�r Hardpan ❑ Previous Application Made: (If yes,[date____________________) No New Construction: Yes ❑ No FHA/VA: Yes ❑ No [] t TYPE OF INSTALLATION AND SACIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.), S pt' 4an : Distance from nearest well_________________Distance from foundation--------------------Material------------------------------- No. of compartments------ ------------------Size--------------------------------Liquid depth--------- Capacity ----_- Disposal Field: Distance from nearest well_5 U_r_____Distance from foundation____,R ' y, ` ___4____.__.Distance to nearest lot line_.?__/��, Number of lines1-------/-_________ __ ________Length of each line_,/)-!------.--_-Width of trench_-__ .; - �. -------- Type of filter material___g_f_ _ _Qt -Depth of filter material___/f_ ----Total length---_------------------ -------- Seepage Pit: Distance to nearest well----------------------Distance from foundation------------------- Distance to nearest lot line__._____________ ❑ Number of pits--;__________________Lining material------____..__ ---- -.size: Diameter- -------- --------Depth---- ----------• - -------- - Cesspool: Distance from nearest well_________________Distance from foundation------------------- Lining material----- r_1 Size: Diameter____ ---9 1 ---- ------------ -----------Depth--------------------------------- ------------------Liquid Capacity- ----- --------- ------•-gals. Priv 1 Y� stance from ne ares+ wel!________________ .-- --- -- -------- --Distance from nearest buildin ❑ Distance to near, g 4 est lot line________________ ---------------------------------------------------- Remodeling and/or repairing (describe)_________________________________ ------------------------------------------------------------------------------------------------ I •----------- ----------------- -------------------------------------------------------------------------- ------------------------- ------- ------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinancesMse41aw , rules and gulations of/the San Joaquin Local Health District. (Signed_____ ------------------------- -- ------- w BY --- ------- -� (Title] n or Contractor) (Plot plan, showing size of lot, locatI of system iri relation o wells, buildings, etc., can be placed on reverse side). - t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ REVIEWED BY ... ------------_-- ------------------------------- DATE------`]5--- �'�,--`c- ----------------------------UILDING PERMIT ISSUED----- -- DATE ------------1- - --------------------------------- --------------- ------------- -----------•---------------- -------------- ------ DATE------------------------------------------ ----------- --- Alterations and/orecommendations:. ..__. ------------ ------------------------------ --- ----- --------------------- --------------------------------------------------------------------- --------------------------------------------- ------------ o FINAL INSPECTION BY:.- .:--��- ----------------- _ Date SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Na:elton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CLT, 3 -