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FOR OFFICE USE: --------------------- --_--- APPLICATION AOR SANITATION PERMIT Permit No. ..r _ .., ------------------------- (Complete in Duplicate) Date Issued -------------------____-------------------------------____ t }This Permit Expires 1 Year From Date Issued Application is hereby made to the Son: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. JOB ADDRESS AND L ION !_lea , o: ---- _------------------ Owner's Name r�� -------------------------------------------------- ----- Phone__------------------------ Address-- .. ------------------------------------------- Address...............` --------------------------------------------------------•-------•--. --------------- Contractor's Name. = # --••------------------------ -- Phone... --- Installation will serve: Residences. artment House ❑ Commercial E] TrailerCourt ❑ Motel ❑ Other F1Number of living units: _I_____ Number of bedrooms .- umber of baths --_!__ Lot size ___ _ I ___WateSupply: Public„system E] Co nmunity system ElPrivate [IDepth to Water Table __ ft. Character of soil to a depth of 3 feei.: Sand ❑ Gravel ❑ Sandy Lown,❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: {lf yes,date____________________) No [ New Construction: Yes No E] tHA/VA: Yes E] No TYPE OF INSTALLATION AND SPECIFICATIONS— (No septic tank,or cesspool permitted if public sewer is available within 200 feet.) ptic�Tak '"a`"Di tante#�o a e twell -_` Die}ancefrom=foundation No. of compartments-------------------------:Size------------------------------..Liquid depth------------- -----------°Capacity----------------------- f ispo al Field Distance from nearest well._: pP._Distance from foundation.-- _____D tante to nearest lot line;______________ Number of lines__ _-__.._. _____ Length of each line_ �___”`.J v__=. dth of trench _- -------------------- Type _ ________________ ) �--` c r 1 Type of filter material_r _/____Depth of filter material___� __________.,_Total length_--_ �__._______________ Seepage Pit: Distance to nearest well-- _.--__Distance from foundation--------------------Distance to.nearest lot line________-____ ❑ dumber of pits---_.-[----------------Lining material----------------------.Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material......;,_________,_______________- ❑ Size: Diameter-----:- ----------------- Depth-----------------------------------------------------Liquid-Capacity_..-------------------=---gals. Prlvy: ,,, .. Distance from4-nearest-we11_�:_ . — ------ Distance from nearest budding ___ _--------------------------------- Distance ____________________ .._._Distance to nearest lot line.--------------------------------------------- --------------------•---------------------------------------- --------------- ------------- Remodeling and/or repairing {describe):__i 'd- - -• °' _r:. __ _ -_ /y " L=Q--- '' •------------------------------ - -----------------------------------•----------•----------------------------------------------------------------------- ----------------- ------------------------------------------------------------ s f �. I hery certify th t I have prepared this application and that +he work will be done in accordance with San Joaquin County ordinance , State law , and rules a 're ulations of the San Joaquin,Local Health District. (Signed) ------- ---- - ---- ---------- ----------------------------------------------- -----(Owner and/or Contractor) BY -• ---------------- -------------------------- (Title) ---------------- (Plot,plan_, showing size, of lot, location of system in relation to wells, buildings,'etc., can be placed on reverse side). I l FOR'DEPARTMENT USE ONLY. ' APPLICATION ACCEPTED BY------------------------------------------------------ ----- ------ DATE------------------------- ._ REVIEWEDBY----------- '------...------------------------------------------- -----------------------------------•---------------------- DATE----- ---- BUILDING PERMIT ISSUED------- ----------------- •---------- — - DATE----------------------e --------- - ------ ------ Alterations and/or recommendations:-'s --- ------ ----- ----------------------------------------- ---•--------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------- ------------------------------ : ------------- ----------------------- ------ -------------------- ----------- ----- ------------•------------- - -----•----------------------------------------------------- --------------------------------- FINAL -----:FINAL INSPECTION BY:--------- - --------- ----- Date-------A� 'c`r �� ------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave, 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,Col'efarnin ES 9 R£VISEO 9-59 3M 3-163 F.P.CO. •� r I