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` //R OFFICE USE: zgj ?_fit.. ----------------02-, �� Permit No. I _s �, y- _,_ -------- APPLICATION F611 SANITATION PERMIT ------------------------------ ------------------------- (Complete in Duplicate) / --------------- __________________ ___ This Permit Expires 1 Year From Date Issued Date Issued ._.___ /C�/ � 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 iCounty /Ordinance No 549. JOB ADDRESS AND LOCATION------ -- Z1-----Ld � - ------------------------------- Owner's Nam Z." ` ?------ - ------ Phone------------------------------------ Address--- __*----------------------------- ------------------------------------------------------------------------------- Contractor's Name----------.� - 1 ------------------------------•---------------•-------------------------------- Phone--------------------------------------------. Installation will serve: Residence ®?Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/__ Number of bedrooms s--- Number of baths '�._ Lot size _ Aar'" ------------------------------- Water Supply: Public system ❑ Community system ❑ Private Er-_Depth to Water Table ___7.0ft Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe R]o-lardpan ❑ Previous Application Made: (If yes,date....................1 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_________________Distance from foundation__--_._.____.______.Distance to nearest lot line----------------- Ak �` Number of lines-----------------------------------Length of each line-----------------------------Width of trench----------------------------------- F� Type of filter material-------------------------Depth of filter material-----------------------Total length----------------------------.._.__________ 04 If o f / _j Seepage Pit: Distance to nearest well--_� __ Distance fr fou dation --------Distance to nearest lot line__ __ ______• (� � X Number of pits______.__--------Lining material---��-Size: Diameter---_7sw.__.-.__.Depth . _ X Cesspool: Distance from nearest well_--____-______Distance from foundation--------------------Lining material-----------------__________-___._.- ❑ Size: Diameter--------------------------------------Depth---- -----------------------------------------------Liquid Capacity----------------------------gals . Q Privy: Distance from nearest well..-_.,--____________________________,_--__.....Distance from nearest building------------------------------------------ t21 ❑ Distance to nearest lotline-------------------------------- ----- -------------------------------------------------------------------------------•-------------------- -------------------------------------------------------------•Remodelin9 and/or repairing (describe): g - ----- T --•------•----------------------------------------------- ------------------------ ------------ -----------------------------------------------------••---------------------------------------------------.-----------------•------------------------------------------------------•----------- ---------- ------------------------------------ ---------------------------------•------------••---------------------------------------------------------------------------------•--------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County A ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. Signed --- __(r.L- r;,r Contractor) By:------------------- -----------------------------------------------= (Title) i - (Plot plan, showing size of lot, location of system in re n to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY / APPLICATION ACCEPTED BY----- ---/--------- - ----- A _--------------------------------------- DATE---------- ----------------- REVIEWEDBY----------------------------------------------------------- ----------------- ---------------------------------------------- DATE----------------------------------------------------------- BUILDING PERMIT ISSUED------------ ------------------------------------------ - - PATE------------------------ ----- ~ wAlterations and/or recommendations: Y �--- . ---------------------------------- ---------------------------------------- --------------------------------------- --------- ------------�------------------------------------------------------------------------------- - FINAL INSPECTION BY: ..... f/--- Date------ ._ -- ->/ ,-------------- ------------ S JOA'U. LOCAL HEALTH DISTRICT t 1601 E.Ha:ellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISED 91-59 3M 3•'63 F.P.CO.