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OR OFFICE USE: ----------------- --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. . � Q _---------------_-- (Complete in Duplicate) -------- --------- Date Issued 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. 5�4/J9.. I 02 0 ` �� r71 JOB ADDRESS AND LOCATION--------------------------------------- !i - ------ - ----------- ------------- ------- ---- v�e�'�-- - Phone.....•---------------- ---_---------• •------------------------------- -------------------------- Owner s Name----- ----------------------------------- -------------- -- Address----------39il--�--- .......& -------• ----------------------------•----------------•------------------------------- -- Contractor's Name------ Phone----------------------------------- Installation will serve: iResidence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [3 Other ❑ Number of living units:A------Number of bedrooms _3___ Number of baths -1----- LotFsiz�. .-_ _X11. -----••-------•-----------=------------ Water Supply: Public system ElCommunity system [IDe Private pth to Water Table 44r ft. Character of soil to a depth of 3feet: Sand ❑ Gravel E] Sandy Loam ElClay Loam ❑ Clay E] Adobe,[] Hardpan E]Previous Application Made: (If yes,date-----------_--------) No Ell," New Construction: Yes ❑ No Vj-� FHA/VAc Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: _ (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ' r i .Sept' ank• � Distance from nearest well-------------_---Distance from foundation--------------------Material________.---__-__-_._._____-____-___.-.._'_____. �y � No. of compartments Size Liquid depth Capacity._.. V k --------- V" f r . 00 Disposa field: Distance from nearest weh__?_Q--------- Distance from foundation_'��._________..Distance to nearest lot Gne__b-- Number of lines--------1------------------ -----Length of each line-1-00_----- -------Width of trench�_o_-",:-------------------- "1 Type of-filter material�45'f______-----Depth of filter material___�_8______-____._Total length-_--_-__ ----------------------------- p(a Yp �. See ge i#" Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- Number of pits----------------------Lining material-----------------------Size: Diameter- --------- -------Depth = Cesspool: Distance from nearest well------------------Distance from foundation--------------_-----Lining material-----________--------------.---- ---- ❑ Size: Diameter--------' ------ --- Depth-------------------------------- -----------------Liquid Capacity- .-------------------------g s " __.-Distance from nearest building E Privy: Distance from nearest well------ -------------------------------- - fi --------- ------------------- ❑ Distance to nearest lot line------------------------- -- -----t------ ' --------------------------------- I ) I Remodeling and/or repairing (describe)=------------------------------------------------•-------- ------=----_------------------------------------------------------------------- --------------- -------------------•--------------------------------------------------------- -- -------------------•------------- --- ------- -----=--------------- ----------------•-----------•-----------------------------------------=` I hereby certify that I have prepare this plicati n and that the work will be done in accordance with San Joaquin County i ordinances, State laws, and rules and r lati sof th San Joaquin Local Health District. t { i ____--_-_.___...(Owner and/or Contractor) (Signed) - -- ------- ------------------------------------ ---------------------- - Title (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-----�--------- -' -----=------ --------------- ------------------- - ----- DATE----- .S?__: f ...... --------------------- DATE----------------------------------------------------------- REVIEWEDBY----------------------------------- -----=- - -------------------- BUILDINGPERMIT ISSUED---------=------------------------------ -------------------------------------------------------------- DATE---------------------- ------------------ --------------- Alterations and/or recommendations--------------------------- ------•-- ------------------------------------ l - ------------------------------------------------------- ------ Y FINAL INSPECTION BY------ `--- �--------------------------- Date -_ ._____.__. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ava. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,eanfornia 65 9 REViSEO 8.59 3M 3-'S3 ""Ca-