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F RFFICE USE: 5_ - JF' ' r /- J APPLICATION FOR SANITATION PERMIT Permit No. 1'� _..�... ._....� -------------=-------------------- ------------------- - (/ A------------------------------ --------------- (Complete in Duplicate) Date Issued - -- / Ilk ...........----------------------------------------------- This Permit Expires 1 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. 1= This application is made in compliance with County Ordinance No. 549. If 4— JOB ADDRESS AND LOCATION_-- ` � - -----------------------------------•-----`--------- Owner's Name ,{�j�F sir ----------------------------------------------------------------- Phone Address --•-•--------- Contractor's Name------- Phone..-- ----- ----- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑! Motel ❑ Other ❑ Number of living units: __I___ mber of bedrooms ;�__ Number of baths -- ___ Lot size Y+ �-l-��'----------------- ------ rr / Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _ffa ; ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Ml-"Hardpan ❑ Previous Application Made: (If yes,date._.:-------.--------) No New Construction: Yes ❑ No k]IFHA/VA; Yes ❑ No g— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S?Wic Tank-, Distance from nearest Well-----------------Distance from foundation--------------------Material------------------------.---________---___-____. No, of compartments--------------------------Size------•-----------------•-------Liquid depth----------- --------------Capacity----------------------- Disposal Field: Distance from nearest well ___" --------Distance from foundation___ --_.Distance to nearest lot line-4 Number of lines_________ _____�...�.-.---. Length of each line_____ Width of trench__ -___ _____-._-_------.___S T /, T e of filter material-: __ L�f _De #h of ,filter material__ - ___��_----_-Total length___._ `"------------------�__-- YP � p Seepage Pit: Disfance to nearest well--------- ---------_Distance fr m foundation-_le.e- --,Distance to nearest lot line__k��_______ Number of pits----- ------------Lining material- A-4----Size: Diameter, ��_----_-Depth_e --- Cesspool: Distance from nearest,well---------- ------Distance from foundation---------------- --.Lining material__________________________________-- ❑ Size: Diameter---------------------------------------Depth--------- -------------------------- ------Liquid Capacity----------------------------gals. tt Privy: Distance from near est.!well--------------___-.____----_---_ ._':____.__.__-Distance from nearest building------------------------------------------ ❑ Distance to nearest lot line-------------------------- Remodeling and/or repairing (describe}:----------- -----------------------•------------------------------------------------------•--------------------- ••-------• ------------------------- ---------------------------------------------------------------------- ----------------------------------------- -----------•----------------------------------------------------------------------------------------------------------------------------------------------------- . I hereby certify that-I-have-prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and r les and regulatio of the San Joaquin-Local Health District. �'� -- ------- --- Igor Contractor) (Signed)----'--------------- - '---------- = By: 6 ---=----------------------- {Title) � �. - (Plot plan, showing size of lot, location of system in rela to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ '' "a------------------------------------------ -----•----------- --- DATE---- '� y REVIEWEDBY------------------------------------------------- ---------------- -----. DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------- ------------------ DATE--------------------------- -------------------------------- Alterations and/or re mmen do s:- ----- ----------------------------------------- ---------------------------u _ 4 --------- -' = -----.-- -- --- ------ ---------�'f ---- - -------- ---- ---- -- FINALINSPECTION BY------------------------------- ------ -------- Date--- - -------------------- ---------------- ------------------------------------ SAN JOAQUI,N LOCAL HEALTH DISTRICT .1601 E.Hazelton Ave. - 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California �' ES 9 REVISEP B-59 3M 3-•63 F.P-CP.