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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. -------------- =--------------------------- Date Issued (Complete in Duplicate) —�� --------------_---------------_---------------------- --- 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 descrbed. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LO ATION-_0 � __ -�' __ :.L:-�_,r / / r -- %- ---L(1� , -�1� ®+�� .��. - Owner's Name-------= --- a. - Phone------------------------------ --° - .---- ------..... - ------------------------------ --------------------------------- Address Contractor's Name-------- t? - -t�------------ - Phone--------------------------------- Installation will serve: Residence ®olpartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/__ Number of bedrooms Number of baths Z--- Lot size ----------------------- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [Clay Loam ❑ Clay ❑ Adobe❑ Hardpan Previous Application Made: (If yes,date____________________) No � New Construction: Yes RT'"no ❑ 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-.1,2(2_'Distance ffrom foundation--M-.-.-_--. ®� No. of compartments-.- __------____-----Size ._____ Liquid depth___ Capacity./- , Disposal Field: Distance from nearest well _�J� __Distance from foundation-aZr-----------Distance to nearest lot line._ ------- [ Number of lines___.____--_-_-, ,___ _- engfh of each line___�p__ __-_"_-_.Width of trench ______ _----_----_-------- Type of filter material-O./�t� epth of filter material---�e�___.__...Total length_,_1"a_a----_-__----_.-__----_- Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------rDisfance to nearest lot line----------------- El Number of pits---------------.------Lining material-----------------------Size: Diameter_'.--------------------Depth---------------------------_-.-.. i Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------- E1 ---------- ---------------❑ Size: Diameter------ ------ - ----- ----------------Depth----------------------------- ----- ----------------Liquid Capacity- --------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------___._ ❑ Distance fo nearest lot lire----------------------------------------------- ---------------------------------------------------------------------------------------- Remodeling and/or repairing (describe)=----- - -----------------�� -----v-------------------------------------------- l -------------------------------------------------------------------------------------------------------•---•------------------------------•--------------------------------------------------------------------------------- ------------------------------------- --- --------------------------------------------------------------------- ----------------------------------- ------------ ----------------------------------------------------- - 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 Districf. Lam--.. (Signed) '�-- / c --- ----(�r Contrac*r] By:--------------------------------------------------------------------- - ------ -- ---------------------{Title] �1 --s---- ---- --------- (Plot plan, showing size of lot, location of syste ' relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- -------------------------------------------------------------- DATE------X0_---17 .404, ------------------------- REVIEWEDBY-------------------------------------------------- ----------------------------------------------------------- ----- DATE------------ -.----- BUILDINGPERMIT ISSUED-------------- ------------------- ----------------------------------------------------------------- DATE------------------------------ ------------------------------ Alterations and/or recommendations--- --------------------------_-------------------------------------------------------------------------------------------------------------------------------• ---------------------------------------------------------------------------- --------------------------------------------------------•-- ----------------------------------- •------------------------•------•------------ sz) X4, �q FINAL INSPECTION BY:t ------------------------------ Date--- --- 7---�-----1-------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazolton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.F.0 C.