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FOR OFFICE-USE-,-- tt� v ------------------ APPLICATION FOR SANITATION PERMIT Permit No. ----- ------------- ------------------------------------------- (Complete in Duplicate) This Permit Exfres 1 Year From Date Issued bate Issued ___� � Applicatio1. n is hereby made to the San Joaquin Lacal Health District for a permit to construct and install theworkwork hrein d�ribed. If a with County Ordinance No. 549. S -�-.._ r-.. a �Owner's Name-------- --- -- ------- 4 # 6 f � Ph Address------------------------ a-- �. - Contractor's Name - --� -------------------- Phone- -��1-. Installation will serve: Residence Apartmente ❑ Commercial L] TraileVize rt ❑ Motel El Other E]/ Number of living units: .- Number of bedrooms Number of baths _ -- ----.-- -..�'P-._---9e ._ -- ?-- _-_____ Water Supply: Public system ❑ Community system Private ❑ Depth_ to ter Table ........ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam��N�o ❑ Adobe ❑ �'"No n ❑ Previous Application Made: (If yes,date_____.___..,_.___.-} No New Construction: Yes FHA/VA: Yes ❑ r .;,,. TY.P_E:O.F„INSTALLATION.AND.SPECIFICATIONS: (No septic tank or cesspool permitted if ubli sewer is available within 200 fe t. Septic Tank: Distance from nearest we f Distan fro `fou a Ltn.-/------------ -Mate�ri�j.. 'C No. of compartments__-. - Size _y ". Liquid dept Capacity/ Disposal Field: Distance from nearest well-_ _ -.....Distance from founJdtion__,��_---_-.-.Distance to nearest 9f line- �_lf ---- Number of lines......3 __----_ Length of each lin ---- -- --- --- ----Width of trench-saw-- Type of -filter materia .9-4-1 _Depth of filter m real-- _l_ - fP _Tot I lengtil----------------- - r,a n Seepage Pit- ,to nearest well--- --------- --_-_-Distance from foun a i6n�`�--- .T- Distance to nearest lot lines`/ ❑ Number of pits----------------- --Lining material-----.-----------------Size: Diameter--------------------_ -Depth_.-..----------------- ----------- Jj Cesspool: Distance from nearest we ___________ __Distance from foundation----------------- _.Lining material---------_---__------_.--_--------_-. J ❑ Sizer Diameter------------ ------ ----------------De th--------- ------------------------------------------ PLiquid Capacity---------------- --------gals. � Privy: Distance from nearest well-------------------------------------------------Distance from nearest building ___ 1 Q ❑ Distance to nearest lot lin - - ---------"- - ----- -----------� -- ----------------------- rt Remodeling and/or repairing (describe 'io ----------- ----------------------------------------------------------------------------------- -------------------------------------- f�0 --------------------•---•-------------------------------------------- ------------------------------------------------•-------------------- ---------------------------------- -----------------------------------------------------•------------------- --------------- ---------- ----------------------•-------------- ------------------------------------- ----------------------------------------------------------- ---------------- 4�[ ------------------------ ----------------------------------- ----=---------------------------__--------------------------' l r,.�r w I hereby certify 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 regula+ionso lthe Sa_`n'Joa:40in Local Health District. (Signed} - 7C_ -- - r ant -- , + . -- -- C Tactor) (Plot plan, showing size of lot, location of system in relafion to we uildings, etc can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---�l�-}-�-�-"•-- - ------------------------------------------ ---- - --------------- DATE------��--- � .. - --- --- ------------------- REVIEWED BY---- ------------------------ IV "".'.. y` DATE_- ` ------- --------------------------------------------------- BUILDING PERMIT ISSUED---------------- ---- -- '"=--------------------------- ----------- #-------------------. DATE Alterations and/or recommendations:_--------------------------------- ------------------•---------------------------------------------------------------------- FINAL INSPE ON BY - '✓.. - ---- ----- ---- Date---- �� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Harellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California 4