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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) Date lssued4}-f` ------------- ------------- This Permit Expires 1 Year From 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 Ordinance No. 549. JOB ADDRESS AND --•-------------------------------------------------------------------•-------------------------------- LOCATION ".��'�- ---/' -----------�--------•••-- Phone. ------------- Owner's Name_--------- r--P, - r�'4---------------------- - c--c/ ---------------•------- Address----------- ---•---------------------------------------------------------•-------------------------------•----------------------------- . Contractor's Name---- e.- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trai4er Court ❑ Motel ❑ Other ❑ Number of living units: ----L Number of bedrooms --- Number of baths . _ Lot size `f--r'---------------------•--- Water Supply: Public-system Community system ❑ Private ❑ Depth,to Water Table _ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑' Clay Loam ❑ Clay ❑ Adobe O'Hardpan ❑ Previous Application Made: (If yes,date-------__..--------) No New Construction: Yes ❑ No ® FHA/VA: Yes ❑ No 0-- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T nk: �f` Distance from nearest well-------------_-_Distance from foundation--------------------Material..----_----.-.-----._.-__----_-----.----------- J No. of compartments--------------------------- Size-----------------------------•-Liquid depth----------- --------------Capacity----------------------- Disposal Field-_ Distance from nearest well-----------.......Distance from foundation----------------_---Distance to nearest lot line----------------- ❑�`1` Number of lines-----------------------------------Length of each lineWidthof trench-------------,--------------------- Type of filter material-------------------------Depth of filter material--- ------ --------Total length--------.-------------- ------------ ----- Distance from foundation-- P---__-_._-- Distance to nearest lot line'____.__._ Seepage Pit: Distance to nearest well---.—:_---_--- f LJ Number of pits-----/---------------Lining material-_. AG- ------Size: Diameter.;5-------- ----- Depth-.-��-------------------- Cesspool: Distance from nearest weil------------- from foundation------------------- Lining material -.-...-__------_-..--___-.-- F1Size: Diameter------------- ------ ---------- ----Qepth------ ----------------------- --------------------Liquid Capacity-- .------------------------gals. Privy: Distance from nearest well--------------------------- _--------------Distance from nearest building----------------------------------------- ❑ Distance to nearest lot line------ ------------------------- ------------------------------ ------------------------ Remode4ing 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,yandrusandregulations of the San Joaquin Local Health District. ' (Signed) + _._._._ ------------ ------------------- ----------------------------- - -----(Owner and/or Contractor) ---- --- - --- - ------------------------------------------------------ Title r (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_ -ry 4---------------------------- ---------------------- DATE__�s -' �J�` �. ' REVIEWED BY- - DATE------------------------------------••-------------------- ------ --- --- ----------------- - BUILDINGPERMIT ISSUED-------------- ---------------------------------------------------------------------- DATE Alterations and/or recommendations:--------------------- ---------------------------------------------------•------------ ---------•-•--------------------------------------------------------------------------------------------•---------------------- ---------------------•------------------------------- ---------- -------------------------------------------------- ------------------ ------------------------------ ---------------------- ----------------------- FINAL INSPECTION BY---- ----- ------- ----------------- Date---- �ZJ------------- ------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.ma:etion Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California ManteCar California Tracy,California F.P.CO. ~ i