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FO)OFFICE USE: • /3 ----_ -- --- ' 1_ APPLICATION FOR SANITATION PERMIT Permit No. .____...... :_ --------------------------------------------------------- (Complete in Duplicate) ` .-_x This Permit Expires 1 Year From Date Issued 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 O dinance No. 549. JOB ADDRESS AND LOC ON � ------------------ Owner's Name------------- _ r Phone------------------------------••---- Address-•-•- .. I------ ------r •----- ----------------------------------------------------------------------------------------• ------•--- Contractor's Name-------."--------- ----- Phone. Installation will serve: Residence eApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ;�__ Number of bedrooms --� Number of baths -A Lot size�.. felf*. � .....'-•--•--------••------- Water Supply: Public system ❑ Community system ❑ Private �epth to Water Table 7111V . Character of soil to a depth of 3 feet: Sand [I Gravel [j Sandy Loam ❑ Clay Loam [I Clay E] Adobe �rdpan ❑ Previous Application Made: (If yes,date----------------....} No New Construction: Yes ❑ No g?, FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well Distance. from foundation---_f0_.___._.Mater'aL [gi� No. of compartments______AW-----_--_.__Size__ _ .. __ _:_..Liquid depth-___ f Capacity__ . -._. f--P-- ---- �. Disposal Field: Distance from nearest w II-- (/______.Dl5tonce from foundatio ._..1A0___------Distance to nearest lot line. ®'r Number of lines___________7 Length of each line______04--------ls Width of trench._____ ..*________________ ---- Type of filter material---- _/� epth of filter material------ length_____ _�___________________�_.. 40-_+_.Dist ce to nearest lot Seepage Pit: Distance to nearest well___f��-Distance fr m found ation_..._Z --- ----•y Number of pits____-----------Lining material.Xf'f_ Size: Diameter._. ,^-.If�___.Depth___ i �__ /f�� Cesspool: Distance from nearest well________________ Distance from foundation P - tion----------------.-_Lining material--- - -•--------------------••-•- ❑ Size: Diameter---------------------- -------------- Depth---------------- - •-• -------------------------Liquid Capacity---------------------------gals. (V Privy: Distance from nearest well------------------�----------------------------Distance from nearest building_________--_--______________________-----. ❑ Distance to nearest lot line.- --- --- -- ---------- --------- ---------------------- ----------- ---------------- � 4 k -- I Remodeling and/or repairing {describe):------------'-------(/_� --- ------------------------------------------------------------------ ------ ---- - ----------•---------------------•••-------------•--------------------------------------• ------- ---------------------------•-----------------=---------•-----------•------------••------------ -----------------------------•--------------------------------------------•-------------------•------------------------------------------------------------------------------------.....----------------------------- 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 r es and regulatio f the San Joaquin Local Health District. .r " "°� ----------------- Contractor) (Signed).-------------------- - - - ---------- --- ----- ----- - ---- ---- ------------- - --- - -- ----------------- { By:------------------------•------ --------------------------------- ---- - (Title)---- "�"A....---- -------------- ---- (Plot plan, showing size of lot, location of system in rel . to wells, buildings, etc., can be placed on reverse side). FO DEPARTMENT USE ONLY - APPLICATIONACCEPTED BY----------------------------- -- ---------- ------ ---------------------------•------------ DATE-----------• -- •------i -------------------------------. ` REVIEWED BY------------------------------------------------------- - - --------------------------------------------------- DATE---------- = °\----------------------------- BUILDINGPERMIT ISSUED---------------------------------- --------I---------------------------•--------------------- DATE----------- --------------------------------------------- Alterations and/or recomme dati s:-_.___4_. _ . ___-____ _ _--- ---.-----•---••------ `- ---- ----ai_x-------- _......;,k-a----------- ----- ------------------------ i ---------------------------- ----------------------------------------------------------------------- ----------------------_ --------------- FINAL INSPECTION BY: Date `r------1 i SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California E0.9 REVISED 0.59 F^c7.2M 6-67