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F FOR OFF4CE USE: _ a p --------- --- _ APPLICATION FOR SANITATION PERMIT Permit No. . .__ �- • ------------------ -�----------------- ---------------- (Complete in Duplicate) Date Issued ------ --- -- - --------- ----------------- -------- . . This Permit Expires 1 Year From Date Issued --------------------- A lication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein describe . l n -------•-----------•-- ce with County Ordinance No. 549. f This application ss madL ATIO � `n complIa JOB ADDRESS AND Owner's Name-------------- - - ----- - - - - ---------------------- Address------- ------------- ,A_�_ ------------------------- -------- Contractor's Name -----•--------- - - Phone-------------•--•-- --•------------ lnstallation will serve: Residence []/Apartment House.❑.. Comrr'ierrcciaal}❑ Trailer Court ❑� Motel ❑ Other ❑ # Number of bedrooms __ Number of baths - Lot size Number of living uni7s-.,-/--- `` Water Supply: Public;system 17-1 Community system Private ❑ Depth to Wafter Table -- � tt. Character of soil to a depth of 3 feet: Sand 4F-1 Gravel F1 Sandy Loam ❑ Clay Loam [I Clay El Adobe'�ardpan E]Previous Application Made: [Ifyes,date:_..-- t� R_-1 No [ ' New Construction: Yes p--17ElFHA/VA: Yes 1[�'No E]TYPE OF INSTALLATION AND SPECIFICATIONS: w (No septic tank or cesspool permitted if public sewer is available wi+hin-.200 feet.} / p I Material_�ir �� Septic Tank: Distance from nearest well - _Distance m f da Septic __ ;', Size-W-07 - Li uid de th-_:_ ._. _Capacity../7,----- No. of compartmenfs� ",------�------ r q p. _ �/ tom' ----- �l I Disposal Field: Distance from ea rest well- Distance from foundation_ .--- Dis#ante to nearest Ij line_ y g �0=Yp --- ------- Number of liners_---_--�____ en fh of each line �71___.Width of french02 x _� e th of filter material-- -. - ---.!--.Total length" > -=-----= y Type of filter -material-/ ----- p -/ "" l / y Distance to nearest lot I� Seepage Pit: + Distance toinearest well_.. . --Distance fr m fou da#ion__ --- --•• �--- De th __off"- -- Number of,pits.... -- --- g Size: Diameter_ y.-- p _ Linin material_ - X_ "- Cesspool: Distance from nearest well---------------Distance from foundation ._.._-_._._______..Lining materia___,__'.___....,__.__.__..______.___ De th -------,----- ---------.Liquid Capacity-- -------------------------gals. ❑ y:. Size: Diameter---------- -----=----------------- P r ____-- _-_._Distance from nearest building.__._-_---:_--_-,--------------------- Privy: Distance from nearest well ------------------------------ "' -------- ------------- Distance ----------- r r, #` --------------------- _ .. Distance to nearest lot Ime---------------------------------------------- - tk r 2/ -- -------•------- --------- Remodeling and/or repairing (describe):_____._._____..___ Y. 1 -----------------------------"------------ ------------------------"---------" ----------------------------- ---------------------- ---------"""------_------- ------"-_-_.._---___.____---___--__----______.._____________._ _._ • -------- . ---_. _ ------------------ ------------ n - -------------------------------------- {f. _-__----_-"___________________________ % — 1---------------------- ---•--------------------------------------------------------------------------------------•-------------------------------------- --------- 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 and regula 'ons of the San Joa in Local Health District. r --- --- ---------------------- (Signed)_ ( Contractor} - - ---- -------- -� By:-------------- ------------------------------------------------------------------------ (Plot plan, showing size of lot, location of system in relation ells, buildings, etc., can be placed on reverse side}. FOR DEPARTMENT USE ONLY l 4 APPLICATION ACCEPTED BY--------- -------- ------------------------------------ DATE ' --------------- REVIEWED BY------------------------------------------ --------------------------------- DATE------ --------- ---•----------------------- PERMIT ISSUED DATE------------------------------------------------------------- ------------------ --- ' r ------- BUILDINGAltera+ions and/or recommendations:.___ ---z �----------- j r f �. �- ---------------------------------- ------------ ------------- ------ ---------- --------------------------- ---------------- _. ----- -- ---- ------------- -------------- �. ----------------------------------------------- ------- -------------- --------- --------------------------------- --------------------------------------------- I i- 1 Date--------------- y -1 FINAL INSPECTION BY:._.-....... � -- -------77—- --- ----- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT reet" i -' 124 Sycamore Street, 205 West 9th Street 1601 E.Hazellon Ave. 300 West Oak St Stockton,California Lodi,California Manteca,California Tracy,California i F.P-CI7• iy'