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FOR OFFICE USE: _. --------------------------------------------------------- - APPLICATION FOR SANITATION PERMIT Permit No. . d. ----- ------------------------------ r r -------------------------------------------------------- (Complete in Duplicate) Date Issued ---------=--------------- ----- --- 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. This application is made in compliance with County Ordinance No. S49. r2 d JOB ADDRESS D LOCA T l(!s 'L�-�'c� f y „ "- ""� - - R-- - - ---r--"'. �.«.� Owner's Name__ Phone----•-------••-------•----------••-- C 4 Address-�--•------ ------ --- ---- ----- ----- c, -_ Phone. Contractor's Name -------- ------------------ --- ------------------ ---------- Installation will serve: Residence ❑ Apartment House ❑ Commercial [Trailer Court ❑ Motel ❑ Other ❑ I' Number of living units: _!� Number of bedrooms _y__ Number of baths _ Lot size ------------------------------------------.-_______-________ Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table -------- 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---------------------) Nor❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public,sewer`is available withit n 200 feet.) . I F I ` Septic an^:, Distance from nearest well-- ..___ .___Dist _ a we rpm hndation_-._ Q____.____.Material____ Ad �p{ No. of compartments_ y__Size._ .f �,. `` f-- 1-Liquid depth--------sCapacity______ - Dispos Field: Distance from nearest well ------Distancejrom.foundation`--!_L?_--__._---.Distance to nearest to r. .. --------- -------Length of each9 .- Number of dines------ ------rt-Y 'line-�A-____----/�'a.-/_2_'. Ididth of trench__2..._----------.------------ Type of filter material----IS__R-______Depth of,filter material----�1_f.__°_.____Total length------13 ________________._ _..- ________ :__: ance froSeepage Pit: Distance to 1. nearest wellf- m foundation____________________Distance to nearest lot line----------------- ❑ Number of pitsA- ', 1 Lining material-------------- --------Size: Diameter--- -------------------Depth--------------------------------- Cesspool: Distance from nearest well__-------____:_Distance from foundation___.___._.._______Lining material_________________ ____________._____. 4 Q Size:.Diameter-----------' = " ---.Depth--- ----- -----------------------------------------Liquid Capacity. - ----------------- gals. Privy: ` Distance from nearest well-------------------------------------------------Distance from nearest building--------------------------------- -------- q ❑ Distance to nearest lot lire---------------------------------- ----------------------------•----- --- ---------------- ------------------ ----- Remodelin nil/or repairing (describe)------------------------------------ --------------------------------------- �1+ ' - 1=--- ----- . ---------------------------- -----------------------------------------•------------------------------------------------------------------------------------- --------------------------------------- ---- I hereby cerci hat I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State ws -and rules and regulations of the San Joaquin Local Health District. I ---- ----------- ---------------- -----can be ace o B __ Title---------- -------------.--- -- - -------- ---- - -- --------- (Plot plan, showing size of lot, location of sydem in rel ion to wells, buildings, etc., placed n reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - DATE_ `9 ��-------------------------------- REVIEWEDBY------------------ -------------------------------------------------- ------------------------------------------------------ DATE----------------------------------------------------------- BUILDING ---------- BUILDINGPERMIT ISSUED--------------------- ---•-------------------------------------.- DATE.----------------------------- ----------------------------- Alterations and/or recommendations: --- ------- ------------------- -----------------------------------------=----------------------------------------------------------•----------------- I'-- ---------------------- ------ / FINAL INSPECTION BY____ _ _ __ __ _ __ _ __ _ Date_S_--' _ ��. -------------- - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Nozeltan Ave. 300 West Oak Street 124 Sycamore Street 205 West 4th Street Stockton,California Lodi,California Manteca,California Tracy,California t F.P.Co. F