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/ FUR{OFFICE USE: ------------t�3re ------ ' ---------------------------------------------------------- APPLICATION FOR'SANITATION PERMIT Permit No. -rl� /�� -------- -------- ---------------------- - ------ ------ (Complete in Duplicate) -------------- This Permit Expires 1 Year From Date Issued Date Issued . _ =_ Application is hereby made to the San Joaquin Local Health District Itfor a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 JOB ADDRESS AND LO TION. - ------ ------------------------- -----j.. �---- ----•- � ---------------------------------- Owner's Name-- ----------- Phone -- --- --•---- . Address--------- 1 , _ ----------------------------------------------------•---------------•------------------------------------- ---- --- ---- - --------------- Contractor's Na --`-------r .S ----- --------•---------- ------------ Phone------------- Installation will serve: Residence 2j'-Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:._'I.__ Number of bedrooms 3____ Number of baths Lot size Water Supply: Public system ❑ Community system Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel [DSan y Loam E] Clay Loam E] Clay ❑ Adobe �ardpan C]Previous Application Made: (It yes,date_____________ __ ) No New Construction: Yes ❑ No (�HA/VA: Yes ❑ No El ' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septi ank: f Distance from nearest well-________._____-:Distance from foundation-------------------Material____--__..__________________.___-_ ._ No, of compartments--------------------------Size------•--------•------------ ---Liquid depth-------------------------.Capacity-------------- --�---- r Disposal ielcl: Distance from nearest wel)__—------ Distance from foundation_ZA___----------Distance to nearest lot-line_5-_-_______ Number of lines___-/-------------------_---------Length of each line___,5_d_---___.__.__--Width of ------------------------ Seepage ------------- Type of filter material�_ti�-a C.k __Depth of filter materiai___f�"------------Total length----�__�----__ Seepage Pit: Distance to nearest well---_—__-...:_____Distancfrom foundation_1L�_----------Distance to nearest lot line__.__.__.1_.-- p .�•;___---- --Lining material___l.Lp_C_Zf--_Size: Diameter.-3_-�__..._.__.__Depth____.ZS_f Number of its__.. _ - ----------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_ _._..___..____-___.__--_____._- ❑ Size: Diameter----------- --------------------------Depth---------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from,nearest_well-___________________________--__�-.,___-_ .__._Distance from e-arest building g ----------------------------------- ❑ Distance to nearest lot line--------------------------------------------- ------- f ------------------------------------------------------------ Remodeling and/or repairing (describe)____--------------------------------------------------- -------------------------------------------------------------------------- -----------------------------------------------------------•-----------------------------------•- ------------------ 1 --------------------------------------- ----- I I hereby certify that I have prepared this application and that the work will be done inE accordance with.San Joaquin County ordinances, State laws:,Rnd rules and regul io of th San Joaquin Local Health District. (Signed) I -------------------- --- - -----(Owner and/or Contractor) By: ------------------------------------------------------------ -----------------------------------------------Title Pot 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-----------------7 ~� ----��-- REVIEWED BY _ r ----------- DATE ---------------- BUILDING PERMIT ISSUED-------------------- - - --�-_----_----__ __��_ - --, -�--�--�----- � ��------- -- �---------------- DANE-------�-------- ---------- Alterations - --- ------- --- --- and/or recommendations:._.__ ~:- -, �- �---__OM1/fes _ e -_ - ��y r �.__t� T --- ---------------------------------------------------------- -----------------------I--------- --------------- --- l. -------------------------------------- ----------------- --------- ------------------------ -------------------------------------- --------------- -- ---------------------------- ------------------------------------------------- FINAL INSPECTION BY-------------------- -- -- t Date 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.P.0 O. (} _r M- 0 ��.