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FUK Ut-HU U51 ` I -------- -------- _!/ APPLICATION -FOR SANITATION PERMIT Permit No. . .4�. ----------------- (Complete in Duplicate) - ___ This Permit Expires 1 Year From Date Issued Date Issued _�_-/7�_ ,� Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the wprk he ein described. I This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION u ----------------•------- Owner's Name___ _ f ✓s _ ------------------------------ -------- Phone----------------------_---------- Address----- -_------•--- Address----- --- --- ----------------------------------------------------------------------------- - - ------------------------------------ Contractor's Name----------- — ----- ---------------------------------------------------------- Phone---------------- ••--------- Installation will serve: Residence Apartment House [] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __A� Number of bedrooms -.- Number of baths _oSr__ Lot size Water Supply: Public .system V---C'ommunity system ❑ Private ❑ Depth to Water Table Zpft Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam E❑ Clay Loam ❑ Clay E❑ Adobe 2--nardpan ❑ Previous Application Made: {lf yes,date_________,_...._I No Z�'New Construction': Yes ❑ No FHA/VA: Yes ❑ No P, TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tan Distance from nearest well________________Distance'from foundation--------------------Material ___..____._________._______________.._-___-____. x'11 G No. of compartments------------- - ----------Size--------------------------------Liquid depth---------------- ---------Capacity----------------------- Disposal Meld: Distance from nearest well-----------------Distance from foundation----------.---------Distance to nearest lot line------------_____ r( !F Number of linesJ---------------------- --------Length of ach line-----------------------------.Width of trench----------------------------------- Type of filter material_________--__ _____ p" o 'to a terial____________________ Total length------------------------------------------_ Seepage Pit: Distance to nearest well `l T Distance fr u tion___ --------------- —/c �--.__._..Distance to nearest lot Number of pits--I__,l_ ----------Lining material--. ,(� _ ize: Diameter-_ e2--___.Depth_,;2 Cesspool: Distance from neares well___________.__Distance from fo dation--------------------Lining material____...__--------_..____.____________. ❑ Size: Diarriefer-1-------------------- ----------De fh-- ----------------------- ------- -------------Liquid. Capacity----------------------------gals. Privy: Distance from.nearest well _________--------__-----___-------_-------------Distance from nearest building------------------------------------_----. r ❑ Distance to nearest lot line----------------------------- ------------------------ ---------------------------I---- -------- Remodeling and/or repairing (describe)____________________ _____ Q - � -------------------------------------------------------------- --------------------------------------------------------------------------------------- -------------- ---- - ---------------------- - --- ------------------------------------ ------------------------ ------------------------------------------------•----------------------•----•--•---------•-----•---------------- ------•---•-------------------- ------ -------------- --------------------------------- --- -----------------------------------------------•-------------------------------------------------- ----------------------------------------------- 0 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 rules al regulations of the San Joaquin Local Health District. 3 4 k (Signed)----------------------' ;6& V - ----- - -------- r Contractor] By--------------------- -------------------- ---------------------------- - - -- - --------------(Title)- /• . (Plot plan, showing size of lot, location of system in rel to wells, buildings, etc., can be placed on reverse side). 41, L :t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY;____c'_____________ :--17_- ------------------------------------------------------- DATE__ - -------------------------------- REVIEWED BY------ ----------- -------------------------------- - RATE BUILDING PERMIT ISSUED i----- ------------------------------- ----------------------------------------------- DATE-------------------------------- Alterations and/or recommendations--- -------------------------------------------- --------------__--------------------------------------------•--- __zl.;/�------------------------- - ----------------------------------------------------------.----------------------------------------------------------- ______-.-___ ----------------------------------- -------- --------------- ------------------ ----------------------------------------------------- -------------------------------------------------------------------------- t I ------------------------------------------- FINAL INSPECTION BY:-- .......... -----__----------------------------- Date----- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ha:eiton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th street Stockton,California Lodi,California Manteca,California Tracy,California