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FOI;j rlCE USE: -------------------=------------------------------------ --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ___1_7 ---------- ------------------------------------ --- ------------- (Complete in Duplicate) ------------------- This Permit Expires 1 Year From Date Issued Date Issued ._�� ---- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the wo herod;eid. This application is made in compliance with County Ordinance No. 549. f - JOB ADDRESS AND LO ATION_/4W_.__lyva •--.� -!€ - 1_`-u ---1 - - -` � Owner's Name r -- ------ Phone Address______ _ - ----------- -------- - -------------- ---------•---- Contractor's Name----- /�-- ------------------•-- -- ----------- Phone Installation will serve: Residence Apartment }-louse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: J--- Number of bedrooms -s?- Number of baths 6p?-- Lot size --------------------- �_____________________ Water Supply: Public system El Community system [_1 Private E] Depth- Water Table`Q ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date---,-------.___:_.__.f No New Construction: Yes rk"%o ❑ FHA/VA: Yes W;oo� No ❑ f TYPE OF INSTALLATION AND SFECIFiCATIONS: k (No septic tank.or cesspool permitted,if,public sewer is available within 200 feet.) Septic Tank: Distance from nearestjw ,�4�P...Distance m fcundati n___A0_--_� No. of compartment_ -----____-------_ _Sizej4�. __ w iquid depth_ ______-.. --------Capacit �_�____-. Disposal Fiefd: - •.Distance from nearest weft.__ _._Distance from found t'on`e ...__._-Distance to nearest mot line__ _______ Number of lines______. _.f.- ength of each lineM �� Width of trent jj Type of filter, material , +._ _- -Depth of filter material..,A -__-.Total length . V1 Seepage Pit: Distance to nearest welL_----------------_____Distance from foundation____-_..-___--..___.Distance to nearest lot line----------------- El Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- I Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material-------------------------------------- El —.Size:.Diameter—.. ----------Depth-------------------------------- --- --------------Liquid Capacity- --------------- - -----gals. Privy: Distance from nearest well----- --_..0---------------------------Distance from nearest building__________________________________________ ❑ Distance to nearest lot line-_-_- -- _ d Remodeling and/or repairing (describe):-------- ----- --------------------------------------------------------- -------------------------------•--------------- ------------------------------ -------------------- ----- P � ----------------------------------------------------- t -------------------------------------------------------------------------•--------------------------------------------------------------------------------------- ----------------------------------------------------------- -r ... --------------------------------------------------------------------------•----- -------------------------------------------------- ------- ---_------------ 1 herebycertify 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 r gulations of the an Joaquin Local Health District, (Signed} ------------------------------ --- ----- Contractor) _ .� Y• - -- ------ --- -- (Title - (Plot plan, showing size of lot, location of system in relati o wells, buildings, etc., can be placed on'reverse side). FOR DEPARTMENT USE O Y . a APPLICATION ACCEPTED BY--------------------- ----- DATE--------___ __--PL.... _---- -------------------------------------------------- -- . -- REVI EWED BY-------------------------------- ----- DATE-- •-------- -------=--------------- BUILDING PERMIT ISSUED--------------------------------- ------------------------------------------------------------------ DATE----------------------- ------- ----------------------------- Alterations and/or recommendations------ --------------------------------------------------------------------------------------------------------------------------------------------------------- --------------- ---• -------- ------------------------------------------ ------------------------------------------------------ •---=----------------------------------------------------------------------------------- ---------•-------•-------------------------------•------ ----•------------------------------- -•------------------------------------ •---------------------------•- ---------------- ------------------------------- / l/ �. FINAL INSPECTION BY:. - !� !,V ------------------ 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 r.R.c o.