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FPR OFFICE USE: ....j�1, -_ r7-l� 11 APPLICATION FOR SANITATION PERMIT Permit No. ..l._ -_ - .. ----------------------------------------------------------- (Complete in Duplicate) --------------------------------------------------------- I 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 Ordinance No. 549. JOB ADDRESS D O ATION.A3___.� �rP Q � �" f' ------�--- Owner's Name ---------------------------- Phone.......----------- Address..---`... �s��' '� ............•............----..... .....................I..............•............................................... ContractorsName.... •---- •' ....-S.._.... .------------------ ................................ Phone................................... Ihitallation will serve: Residence [D'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ._____ Number of bedrooms ._3-. Number of baths ./4 Lot size ----��~ ------------------------------ Water Supply: Public system ❑ Community system ❑ Private Z Depth to Water Table I ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 10 Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,datej.�/�/l-------) No ❑ New Construction: Yes 8 o ❑ FHA/VA: Yes ❑ No 93-- i T1 k OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r - Septic Tank: Distance from nearest well___�`d_.__ Distance from foundation_1�----__---------Material.... -��_n_ d... .............�.. No. of com artments_______-. 1 P z--------- ----5ize_.�,5 X--�-�-------Liquid depth--��-��--------Capacity----��:P..4?�f'.u� , Disposal Field: Distance from nearest well_. ----------Distance from foundation_____ 17----------Distance to nearest lot line,_!�....... [B' Number of lines------------------2-----_------Length of each line-----7 ---------------Width of trench--------------- Type of filter material.......Q -------Depth of filter material---Z8:y------------Total length------./s�_._6......................... Seepage Pit: Distance to nearest well_JaI__------------Distance from foundation_/!..............Distance to nearest lot line__�� ._._.. ❑� Number of pits-------2--------Lining material... !(_._-.Size: Diameter__-33.`_-._____- Depth-------- _0-'______________ 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-..-------------------------------------------------------------------- ------------------------------------------------------------- - Remodeling and/or repairing (describe)---------------------------------------------------------------------------------------------------------------------------------------•-----------.._... ----------•---------•-•---------------7............................................................----•---•--•- ---••-•-•----- .......-------------------------....------------------------------------------------ ------•-----•-•----------•---------- --•------------------•-----------•-••-------•--•---------•-••-------------------- -------------------------------•---••------------------------------------------------------------- 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 regulations of the San Joaquin Local Health District. (Signed)................................................. ----- -- ----------------------------------- -----------------------------(Owner and/or Contractor) BY= --- --- -- -- (Title) (Plot plan, showing size of to , ocation of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTEDBY- -- - ---- ------------------------------------ DATE-------/�-r f 1° -------•---- REVItWEDBY-------------------------------------- ---•----- - ----------------------------------------------------------------------- DATE----- •--------------- BUILDINGPERMIT ISSUED...:...:------------------------------•---..------------------............................---------- DATE------------------------------------------------------------- etitans d/or recommendations---------------------------------------------------------------------------------------------------------------------------------------------------------------- . .... ..CP� - ----- - - - .--•--- -•-•--•----•--•-------------•---••--•---.--.-----.---------------------- ....... -_-.-------•--••-----------•--•------ ---- ---- -- -----••-•-• -------._..-_---------. --------•---•--------•---------- FINAL INSPECTION BY:_ .. -- - ---- -------------------------- Dafi - / ------------------------- 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 • 90 9 REVIs Eo B-091 2M a-61 AILAB