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FOR OFFICE USE % =i - --------------- -- ------------- - APPLICATION FOR SANITATION PERMIT Permit No. - ----------------------- - - (Complefe•in Duplicate) -- - ----- -- - - - -...__._____.._._..__..____..__..-- -.------------ __" This Permit Expires 1 Year From Date Issued DateIssued 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 a e i com is with County Ordinanc No. 549. JOB A S OCATI N- ------ --`1�d---- - - -------------1----------- ---=--------�------------- Owner's Name_.__ _ - One - - -- P Address_____________ ^ Contractor's Name- ---._ -- ---------------- - ------�---• • - -- ----- - ---- - -- - - - -- ------------------------- ------- Phone.._..------------------------------------ Installation will serve: Residence Apartment House ❑ Commercial'❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: `:_®:_. Number of bedrooms_-_ Number of baths_-Lot size _._-_ --'-' __--.__--___-___-_.--._ t ,a Water Supply: -Public system ❑ Community system ❑� Private Depth to Water Table ------ . ft � Character of soil to a depth of 3 feet- Sand ❑ Gravel 0 Sandy Loam ❑ Clay Loam ❑ Clay Adobe ❑ 'Hardpan ❑ Previous Application Made: (If yes,date_-------_ ----__ J N'b,r[_N Mw Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: t (No septic tank or cesspool permitted if public•seyver is available within 200 feet.) Septic nk: Distance from nearest well_ ll.__f__....Distancgg`�rom foundation__�4__ --------Material- .............._ ._....__-____-.._y_._ ___. No. of compartments...--_,� _ ....__Size_ l�.__X I._X S..__Liquid clepth_____j1_ ------ _____._Capacity _.- Dispos Field: Distance from nearest well-10-r-----Distance from foundation..1d...........Distance to nearest lot line_____ Number of lines.__.____ _. Len`g`th of each line_..._/. F�................. Width of trench_ -.�______________________ _ } r Type of filter materiaL' � '_.___Depth of filter material---_...1 - Total length___ Q_Q________________________ Seep e Pit: Distance to nearest well"'-__ from efoundation---- _4!-------Distance to nearest lot line... _-___..._ Number of pits___ -_ _ ___ Lining material_- 4_ .`-_---- Size: Diameter---33...........Depth_-,2—J'................... Cesspool: Distance from nearest well ----------------Distance-ftom foundation................. _.Lining material--......___._______._________._______ ❑ Size: Diameter FDeth Liquid Capacity -------------gals. # Privy- Distance,fr:.om nearest well -Distance from nearest building J _ 9 ❑ Distance to nearest lotdine- . - - ----"---------------------------------------------------------------•------- --------=----------....---- Remodeling and/or repairing (describe)j-------- ----------------------- ---- ------ --- -1----------------------------------------------------------------------------------------------------- ---------------------------------------------------I----- ---------- --------- ------------------------------- ( --------------------- --------------------------------------------------------------- { t --------- -------------=----- ------------- ----------------------------------- ------------------------ ---- ------------------------•------------------------------------------------ I hereby aat I have prepared this application and thaf the work will be done in accordance with San Joaquin County ordinances, Stand rules an regulations of the San Joaquin Local Health District. (Signed)---------- --- --- - -- --- -= -------- - ------ ------- ---- ------------ -------------- --- - -------- --------------------�nd/or Contractor) BY� -=------------ --------- - -- --- - -------------- --------------- - ------(Title)------------------ - .... Plot plan, showing size of lot,'location of system in relation to wells, buildings, etc.,-can-rbe.-placed-on rreverse side FOR DEPARTMENT USE ONLY P APPLICATION ACCEPTED BY .- �C �1 ,f------------------------------------ DATE-A.-..Lt '�r. ------------------------------- REVIEWEDBY ---------------------'-------- -------------- r------------ --------------------- ---- --------- ----------------- DATE------------------------------------------------------------ I BUILDING PERMIT ISSUED = ---- ------------------—----------------------------------:-- DATE---------------------=_ '-------------- _. Alterations and/or recommendations:------------------ '....----------------- --- ---------------------------------------------------------------------------•- ---- ------------------------ ----------------------- ------------------- ----------- --•----- ...................... ----------------------------------------- ------------------•------------------------------------------------------ -------------------------- •----------------- ......................... ----=------------- ----------------------- --------- ---------- -------------------- --------------- -------------------------------•-- ---........ .- ---- .._...------- ----------------------------- - ------- -- --------------- FI . s NAL INSPECTION BY:_ ,:..: r ....:. . . --- ----------- Date.- -` `---- -�----- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ha:ellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9Th Street Stockton,California Lodi. California Manteca,California Tracy,California E.H.92M 1-67 Vanguard Press J i ,.w-.. A