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FOR OFFICE USE: --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .,;2al .._� (Complete in Duplicate) Date Issued --- -------------------- ---------------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joa uin Local Health District for a Ee.rmit to construct and install the work herein described. This appiic�tion 'sZ[�LO�ATI madin lian w' �',ry No, 54� �G I R�5 JOB ADD E '^ -- 0-� Sb/lyl.(, S v V✓, '�cr� # Owner's Name ,_/¢- r1� -1 ` j--------------------- --------------------------------- - Phone.f k J sT/i f S' 1—I ---------------- � _ Address--------------- - - - -- -------------l-�------ �`y ---`--------- ------- Li 1Pc Contractor's Name C -/- '------ '� �4 i'�`VL�c ` ' --------•------------------ Installation will serve: Residence B— Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of.living units: -1----- Number of bedrooms - --- --- ---------- 1 - __ I x / _______ Water Supply: Public system ❑ Community system ❑ Private P Depth to Water Table 3_0_ ft. r Character of soil to a depth of 3 feet: Sand R- Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan k J Previous Application Made: (if yes,date----------- ] No g�' New Construction: Yes Ej No ❑ FHA/VA: Yes ®^ No [ f I. TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet:) f Septic Tank: Distance from nearest well----�._9._/....Distance from foundation__._/Q_______.__.Material__��_�_C-�-�--._� _______.___.. , 921, No. of compartments_..__- Size__ 6_'X-�1_•K_ __Liquid depth___.__y__�...___-_---Capacity _�4_�`: _ Dis osal Field: Distance from nearest well---) -Q---...-Distance from foundation___i .-____.._.Distance to nearest lot line__"a�.__-_____. Number of lines-------- I ---------------------Length of each line-------6 -----------------Width of trench-_-_- `----------.------------- Type of filter material._. -------Depth of filter materiaL___� ��_..._-Total length-------!_Z.`----------______________ f' Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__-___..____-__._ ❑ Number of pits--------------------- Lining material------------- Diameter_--------------------Dept k------------------------ -- 1. � Cesspool: Distance from nearest well-----------------Distance from foundation.--......-----------Lining material-----------------------------------.-. ❑ Size: Diameter-------------------------------------Depth---------------------------- - ------------------Liquid Capacity-------------- -----------gals. Privy: Distance from nearest well-------_-----_-----------------------------------Distance from nearest building------------------------------------ ---. ❑ Distance to nearest lot line------------------------------------------ ------------------------------- ---------------------------------------------------------------- i Remodelingand/or repairing (describe}-------------------------------------------------------------------------------------------------------------------------------------•------------------- ---------------------------------------------------------------------------------- ------ -------------------•-------------- -------------------------------- ----- -------------------------------------------- -------------------------------------------------------------------------------------:-----------------•—---------------------------•-------------------------- -- ---------------------------------------------------- ------------------------ ---------------------------------------------------------------•----------------------------------------------------------------------------------------------------------------------------------- I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. -------------------------------- - ' - --------------------------------(Owner and/or Contractor) (Signed)-----�----- � ' By:-------- ----------------------------- -----------------------------------------------------------------(Title)----------------- ------- -------------------------------- (Plot ----------- -(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ ' ��'O"°' ,`�------ ------------------- DATE----- --7 REVIEWEDBY----------------------------------------- ------------------------------------------------------------ DATE---- - -------------------------------------------- BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------- DATE Alterations and/or recommendations:-------------- ...... r ------------------------------- ------------------------------------- -- ------------------ ------ ------------------------------------------------------------•----------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ - -------------------•----------------- -- --------------------------------- ------- --------- -------------- ----------------------- ------------ - -- -------------------- - ---------------------- ---------- -- ------ ---- ----- r I FINAL INSPECTION BY:.------ t G------ ---------- Date-.----- - = ---------- ---- ---------------------------- S N --------------------------SAN J IN LOCAL HEALTH DISTRICT 1601 E.Hazellon Av*. 300 West Oak Street 124 Sycamore Street 205 West 41h Street Stockton,California Lodi,California Manteca,California Tracy, California F.P.CO.