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FO.RQ FICE USE: APPLICATION FOR SANITATION PERMIT Permit No_ _ _______............. _ --------------------------------------------------------- (Complete in Duplicate) Date Issued __________________________________________________ j 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. 549. E JOB ADDRESS AND OCATIOf !__ _.GI -1--- ` A1' /� - Owner's Name---------- I" L_P7--k- ---------------------•------ ,-,-- -----------m-------- --------- -- ----- - --- Phone------------------------------------ Address__ c - !/ -------------------------------------------------------------------------------------------------------------------------- Contractor's Name Q 6 f,P-- ,/_.------------------------------------------- ----------------------------- Phone--------'` --------- Installation will serve: Residence RT-Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: A. Number of bedrooms Number of baths A-_- Lot size ____________________ Water Supply: Public system ❑ Community system �rivate ❑ Depth to Water Table 1P ft. s` Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe E] Hardpan ❑ r Previous Application Made: (If yes,date..'----------------I No Kr New Construction: Yes E-] No ®""'FHA/VA: Yes ❑ No ?g 4 TYPE OF -INSTALLATION AND-SPECIFICATIONS: i (No'septic'fa'nk or cesspool-permittedYif public sewer'is aVailabl"ithin-200'feet:] E Septic Tank: . Distance from nearest well_________________Distance from foundation....................Material------------------------------______--__________- 1 'ls111� ' No. of compartments----------------- - ---Size-------------------------------Liquid depth---------------- ---- ----Capacity....------------------- s 0 Disposal Field: Distance from nearest well_____-____Distance from foundation.,ele-_____--_.Distance to nearest l� line__w�`�--------_..._ Number of lines______, ___ Length of each line.l� _--._ I.__.Width,of trench_�__ ---------------_----____ C Type of filter material( _Depth of filter material_ -------Total len gth_ iE _____________________._ Q Seepage Pit: L Distance to nearest weft--------___-----------Distance from foundation-------------------Distance to nearest lot'line----------------- -1 ❑ Number of pits..-.-----------------Lining material-----------------------Size: Diameter_- '.--Depth--------------------------------- 1 N Cesspool: Distance from nearest well._---------------Distance from foundation....----------------Lining material__-__--------------------------------- S'ze- ___..____.___.__.__--_---_.Size: Diaineter'3--- -Depth-------------------------- --- ---------------------Liquid,Capacity----------------- ----------gals. � I Privy: Distance from nearest well_______________________ _--------__.----------Distance from nearest building------------------------------_....._. ._. ❑ Distance to nearest lot line......... _______ ._. t Remodeling and/or repairing (describe)=-------------40 - � ---- ---------------------------•----------------------------------------------------------------------------=---- - ----------------------•-------------------------------------------•--------------------------------------- ------------------------------------------------------------------------------=-----------•-------•----------------------------------------------------------------------------------------------------------------------- I hereby certify than have prepared this application and that the work will be done in accordance with. San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. .-� (Signed)----------=-- ��,t 'L, -- --- -- ----------------------------------- {�r or Contractor] i (Plot plan, showing size of lot, location of system i lation to wells, buildings, etc., can be placed on reverse side). t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- ---- ---------------------- ------------------------------------------- DATE------ - =46 " REVIEWEDBY-------------------------------- --------------------------------------------------------------._ DATE-------------------------------------- BUILDaING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:.----- ----- - ---------- ------ ------•----------------------------------------- ----------------•------ ----------•---------------------- --------------------------- -----------_--------------------------------------------------------------------------------------------------------------------------------- --------------------------------------- ------------ ---------------------------------- . -----.-------- ------- --- ---- ----------------------------------------------------------- ------------------------ - .. "---------------------- -- � 6&i ---------------------------------------------- FINAL INSP Date-- ------------- - -- -+ --- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi, California i Manteca,California Tracy,California F.P.CO. I