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FOR OFFICE USE: APPLICATION FOR- ----------------------- SANITATION PERMIT Permit No, ..- a_--<<- -------------------------- (Complete in Duplicate)------------------------ Date Issued 1 This Permit Expires-----------------------------------"---------------. w - ate Issued ll Year From D _ Application is hereby made to the San Joaquin Local Health is riot or a permit to construct and install the work herein described. This application is made in compliance with Qounty Ordina e N 9. e JOB ADDRESS AND - ATION_ ---------- --------- --- - ---..--•--------------..................,..-------------------------------------------- --------- . Owner's Name....- _ Phone---------------------------- -..._--- --- ----- -- --- Address-------------------------A/ ------- ------: - ------ --------------------;--...--------`--------------------- ----------------------•---•------------------------ ..................... Contractor's Name--------------------------•---- - - - --- ------------------------------------------------ Phone............................ ........ Installation-will serve: Residence.jal"'Apartment House'[] `Commercial El Trail r ourt ❑j Motel ❑ Other ❑ Number of living units. ..l:_,-_ Number of bedrooms ZNumber of baths -/ of size ------ ----------------------- : Water Supply: Public system Community system [I Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gra el Sandy Loam ❑ Clay Loam ❑ Clay F] Adobe JK Hardpan ❑ Previous Application Made: (If ye§,ae�p__._`- i'� ]--New Construction: Yes [2-""N ElFHA/VA: Yes El t2"' TYPE OF INSTALLATION AND SPECIFICATIONS- (No septic tank or cesspool permitted��jqubli sewer is available within 200 feet.) �J /� . � Septic Tank: Distance from nearest weil___ __ .Dis#ante ffom foundation----/Q__.-_,___.Mat ryal:_• ___.____ :_- C No, of compartments----- _-,_1`FSize__--�1� ------Liquid depth------�_'------------Capacity-_--_ Disposal Field: Distance from nearest well'.,-----Distance from €oundatio _G0__ Distance to nearest lot Jine___ _,- Number of lines____ -___ :e, _ __.-Length of each line_.____ __._______ Width of trench.- Type of filter mateDepth of filter material____.__--------Total length_______ - -------------------------- Seepage Pit: Distance to nd'arest well-----------------------Distance from foundation--------------------Distance to nearest lot line------------------ Number of ---_-_-__-__-.._Numberof pits---------------•------Lining material---------------_-------Size: Diameter------------------------Depth--------------------------------- Cesspool: .---------------- ------Cesspool: Distance from nearest well------ --------Distance from foundation-. _--:_--_.Lining material--..---_-_------____--_-___-I.—...... ❑ Size: Diameter---------------------------------------Depth----•---------------------------------------------x Liquid Capacity ---------_--------- --•gals. t Privy: Distance from nearest well--------------------------________.-__-___.-___-Distance from nearest building-----..------------_---_---____-__.-.._._. IN ❑ Distance to nearest lot line,.' -------------------------- ---- -------------------------------------------------------------- i 4 i Remodeling 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, St laws, and rules and'regulatjons"of the San Joaquin Local Health District. l :... .---•- ••-- ----- ----- ' f s (Signed)• = -------------------------------- Owner nd/or Contractor) By=------------ ...... ..... .-------------•-•------------ ` - -----------------------------------------------------(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 i 1. APPLICATION ACCEPTED BY------- ----- --- ------ --------- ---- ------------- ----------------------------- DATE............ --------------------- REVIEWED. ------------- --REVIEWED. BY------------------------------------------- - -- - ----- -------------------------------------------- DATE---------- --- ----- BUILDING ---BUILDING PERMIT ISSUED---------------------- -- --------------- •------------ DATE--------•------------------- i]Iterations and/or recommendations:_ -----------------=---------•-- ---------------- ----------------------•---- ---•------------------------------------------------------ ------------ ----------••-----------••----------------.----- _./-- ------ - ---'=---------' --------'------ -----------.-.--... . --_._----------------------- ` r - ------� .-- - -- ----------••----------- ------------ --- -----•-•--------------------- --- -------- ---------- -- - ----------------------------------.-----------•----- -------------------------------- ^ - k FINALINSPECTION BY ..------- -----------------------------------•------------- Date-------------------------------------------------------- ..:_ 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,CaRfornla E13•9 REVI6EC 8.69 r.P.CG.2M 6.66 1