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FOR OFFIC7 USE: tr p X932 S 1�-------- APPLICATION FOR SANITATION PERMIT Permit No. ---------------- -- (Complete in Duplicate) Date Issued ............ This Permit Exl2ires 1 Year From Date Issued ............. ..{2 Application is hereby made to the San _ si"wr4`Local Health District for a permit to construct and install the work herein described. This application is made in compliance W.4.W:Cdunty Ordinance No. 5,49. & a ' f k JOB ADDRESS AND LOCATION-._._ __ _.. __ -------------------------.--------------------------------------- Owner's Name__.__�jPhone / ---------------- Address--•-.4_6_.1_rr��_. f 1fI�.=_ �Q n ContractorsName --------------------------••------------------------------------------------------- Phone------------------------------------ Installation ---------------- ------•-------••-Installation will serve: Residence �partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ .___ Number of bedrooms .�3--- Number of baths ___�___ Lot size ---------------------____.......__--------__________________ Water Supply: Public system Community system ❑ Private FeDepth to Water Tabl _ tt. ) Character of soil to a depth of 3 feet: Sand [] Gravel ❑ Sandy Loam E] Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ � a Previous Application Made: Ilf yes,date____________________) No PT" New Construction: Yes B-No ❑ FHA/VA: Yes �o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) E Septic Tank: Distance from nearest well___--r!�___.__Distance from ®� 37 `fo�undation_/4_---_-.-_--.Material_ ------------------------- No. ________ __=__'_°__ No. of com artments__.: . c_---Li uid de tn______ ____ _ ____--- Ca acitY---- _ r Disposal Field; Distance from nearest well------_------Distance from foundation__40-_ ______...Distance to nearest lot line_s._r p� Number of lines _-14—.�---._ F ------------Length of each line---Z Ste_`_-.___"__.Width of trench--- - .-`'__..__._____.__ , t Type of filter material___J_l_"T_----_Depth of fiiter material____ r---`---------Total length--_-vt``�__'------------------ .__-_ t r � Seepage Pit: Distance to nearest well------ Y'------------Distance from foundation___fd_w____--.Distance to nearest lot [ine_a� _f___ N4mber of pits___ . __Lining material___�L/(-.--.Size: Diameter--___3- _s.._. Depth___.2_d------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material______._.___._._____._____-.-____-_- - f a acit El Size: Diameter-------------------- ---- ------ - Depth- ---------------------- ----------------------___Liquid CP Y-------------------- -----gals. Privy: Distance from nearest welli---------------------------------------- ---__Distance from nearest building_t------- _____________________________ ❑ Distance to nearest lot line--.-----------------•=-------- ---------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):-- ------ - V--- ---- - --- ------- - --------------------------------------------_•---------------------•------------------------------- r ------ - ---- ---------------------------•------------- ------------------------ ------ ----------"---"--"--------------------------•------------- --=-------------------------------------------- --------- ---------------------------------- ------ --------------------------------------- -------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and`that the work will be done in accordance with San Joaquin County ordinances, State I Vws, and rules a d regulati ns of the San Joaquin Local Health District. { r (Signed)---------- - - =" -------------- - ---------------------------------------------------------- -------- ----(Owner and/or Contractor) B 4 (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 APPLICATION ACCEPTED DATE__ '- ------------------ BY----------------------------------------------------- ---------=----------------------------------------------- DATE------------ BUILDING PERMIT ISSUED----------------------------------------------------------------- ;-------- -_- ---• DATEt---------------------------- ----- Alterations and/or recommendations—.- - 6 - ---------- -------- ------- ------------- �4 - -------------------------------•---•---------------------------------- ---�.-----� - ----- --------------------------•------- FINAL INSPECTION BY:--- 5-,.-. '�� Date------- -� - �T- 5 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.e,C O. � r