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FOR OFFICE USE: 1----------------- APPLICATION FOR SANIT TION PERMIT Permit No. .__. ..._ --------------------------------------------------------- (Complete in Duplicate) Date Issued ----------------------- _. This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549., JOB ADDRESS AND LOC N---- l - -------- ��',`' ------------- ------ ..................... .................. Owner's Name-------- ------- -------- Phone.-- , Address------174Z16a--- ----- ---- I--------=---------- ----------_-._.- Contractor's Name------1.,i ---------------•---------------------------------------------------------------------------------------.-..._- Phone---------------- ---•-------------- e Installation will serve: Residence [Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/_._ Number of bedrooms _ _- Number of baths ---/__ Lot size ____/----- -------------------- Water Supply: Public,system ff-C'ommunity system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeHardpan ❑, Previous Application Made: (ifyes,date------------------ ) No New Construction: Yes ❑ No ❑FHA/VA: Yes ❑ No i TYPE OF INSTALLATION AND SPECIFICATIONS: `t (No septic tank or cesspool permitted if public sewer is available within 200 feet.) C Septic Ta k: Distance from nearest.well- _-___Distance from foundation-___l Q_---_-- Mat�eff lair!---il- ___--------_______ �. , _- C_ID?---Liquid depth-------7 --f___-Capacity-_._L No. of compartments--____-�-�_._ -_____Size-_ ___ - Disposal eid: Distance from nearest well, Distance from foundatio ___ ._ll-I----Distance to nearest lot line____ __-j_-- r V Number of lines----------------I_________-�-____L Length of each line________ .-Q_r--.________..Width of trench______ -_ _____.-___.-______-_ Type of filter material-_- Depth of filter material-----6--- . -_ __Total length--- --_________-_-_________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance:to nearest lot line---____________ ❑ Number of pits----------------------Lining material----------'-.---------.Size: Diameter------------------------Depth......'-------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation ___.__..Lining material------------------------------------- . F] Size: Di meter Depth -----------------------------Liquid- Capacity----------------------------gals. -� Privy: Distance from nearest wellf------------------------------------------------Distance from nearest building__________-_._--____________.____----.. ❑ Distance to 'nearest lot line----------------- -- ;----- --------------------------------------'------------------------------------ --------- Remodeling and/or_repair.ing-(describel:------- = 1: � l=�l ---------------------------------------------- r ---------------------------------------------------------------------------- -----: / ------ I hereby certify that I.have prepared this application and thai the work will be done in accordance with San Joaquin County ordinances, State lawp, and rule and r gulatio s f the San Joaquin Local Health District. (Signed)----- - -- ---------- -------- :` --(Owner and/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 - APPLICATION ACCEPTED BY-------- --- ------'- ------'-------- -'---------------------------- - - `�- DATE------ -----?----------------------------------------- - - REVIEWEDBY------------------------------------------------ ------------- ---------------------------------------------- DATE------------ ----------_:---- ------------------------- ' BUILDING PERMIT ISSUED-------------------------------------- - ----------------------- --------- DATE----=------------ --- Alterations and/or recommendations:.__----,� - - -- /'-------'---_-- --------- ----- --------------------------------------- ------------------------ ---------------------- --- { -------------------•------------------------------------------------- -------- --------------------------�.-------------------------------------------------------------------------`--------------------------------•--- --------------------- } --------------------------------------- ----------- - 40 - N11na � ''---- ------------------------------ SAN FINAL INSPECTION BY:. -'-'a-'- -F-�'-- � ----------------------------- $ ate_ ---- -'--' ------ ------'---- ' -' '------'-'-'--'---------•--._ .. i SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street I Stockton,California Lodi,California Manteca,California Tracy,California