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/ FOR OFFICE USE: / APPLICATION FOR_SANITATION PERMIT Permit No. ..,/ .__-_ . .. ----------------- ----------------- -------------------- (Complete in Duplicate) / G$' --_._.__-.- This Permit Expires 1 Year From Date issued Date Issued _____ ! Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with �� County Ordinance No. 549. JOB ADDRESS AND LOCATION-------- -`I `� � - Owner's Name--------------------------------------------�--0------�------- u4 N Phone._ ____ Address------------------------------------------------------ ----------— ------------ ...L-N-------- •----------------•�----r--- ------------------------- Contractor's Name ---------------- Phone"T- - -- 7 '4 ' � Installation will serve: Residence P"Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ?t-- Number of bedrooms 3.. Number of baths _ Lot size _-- 3_-_k__h_Q-Q----------------_______ yWater Supply: Public system R Community system ❑ Private ❑ Depth to Water Table 40 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No New Construction: Yes ❑ No FNA/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_______---_____Disfance from foundation--------------------Material________-.-.____________________________________ ❑ No. of compartments--------------------------Size----------- ------Liquid depth -------------= ---------Capacity----------------------- Disposal Field: Distance from nearest well.-----------------Distance from foundation----l_Q_r__-__.Distance to nearest lot line__h?________ Number of lines------------------I�----------------Length of each line----------------- '. of trench----- 4��`_----.------------- Type of filter material-_ _.V4 C Depth of filter material---_-11�_«------Total length--------------!_._�__-_---__________ r i SeX Pit: Distance to pnearbst well---___--'_.._g_--Distance fro foundaZe npl/ ......Dista Distance to nearest lot liner�__S�------ X Number of its...-----�-----------Linin material---5-_(?CKs i�$- ---- Depth......zS------- -- - - -- i 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--- -------------------------- -----------------------------------------------------------------r------------------------------------ _ Remodeling and/or repairing (describe: C--.L--------L�-- ----------L-- - -----------------------5 , (`- - --------------- Q' ---- ----------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------=------------------------------------------------ -- ------ -- I hereby certify that I have prepared this application and that the work will be dome in accordance with San Joaquin County ordinances, State laws, and ruiIp&and regulations of the San Joaquin Local Health District. j42rL\ i rand/or Contractor) -------------------------Ow(Signed)-------------�------------------- -------- x [Ti+le)By:---- -- ............................. -•- - ----------------------------------------------------- ------------------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- = (— -�----------------------- DATE-------. ,�/�A- - -------------- REVIEWEDBY------------------------------------ -------- ------------------ DATE / BUILDING PERMIT ISSUED--------------------- � -- DATE--------------------------------------------- --------------- Alterations and/or recommendations:------ _---- ------------------------------------------------- ---------------------- --------------------- ------- ----------------------------------------------------------------- ----- ----------------------------------------------------------------------------- ------------------- ---------------- ------------------------------------------------------------------------ -------- ----------------------------------------------------------------------------------------------------------------------------------------- -------------I------------------------------------------------ - ------------------------------------------ ------------------------------------------------------------------------------- ------------------------------ FINAL INSPECTION B — y ---- - ---- Date---------�-----y�-�-f-- � — ----------•----------=/.------- - i _ SAN JOA N LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California r•.P.ao.