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FOR OFFICE USE: �------------ ----------- �-�_-��t-fly------ - ' � f =��:�•�:-_ . APPLICATION FORS SANITATION PERMIT !Permit fNlo, ------------- _-- ---------- ---------------- ---- (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 LOCATION____________________-------------------------------- _ Owner's Name----------- ----- --------- ------ ---- Phone_!_ ^�J --- ------------- - ----- Address - -- �� --- ---- Contractor's Name Phone ��'� —3/ /7� Installation will serve: 'Residence �partment House ❑ Commercial ❑ Trai4er Court E3 Motel [I Other ❑ Number of baths __/__ Lot size ______ ___ -3 -__-------------- Number of living units: __ - Number of bedrooms ---- Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table * 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---_- I No 2?--'�ew Construction: Yes ❑ No ®SHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: L � (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ` Septic T Distance from nearest well_ __--.-' __Distance from foundation__-1- ------_Matenal-_ ----_._.__ ._.__ No. of compartments---------��-----------Size---�1�_..9 ---------Liquid depth-..$.....--............Capacity.. ---4q- ------ sp�o al Field: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line____----_-_-_____ Number of lines-----------------------------------Length of each line_----------------------------Width of trench--------------.--------------------- \ Type of filter material-------------------------Depth of filter material-----------------------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----------i-___---- Lining material------------------------------------- ElSize: Diameter---- --------------- ------------Depth--------- -------------------------------- --------Liquid Capacity---------------------------gals. Privy: Distance from nearest well------. -----------------------------------------Distance from nearest building----------------------------------------_. ❑ Distance to nearest lot line---------.- ------------------------------ -------------------------r------- -- ----- 00, Remodeling and/or repairing (describe :__. _.____ - --- - - - ------- ------------------------------ l --------- -------------------------------------------------------------•---------------------------------------- ; ------•-•----------------------------------------------------------- ------------- 1 --------------------------------------------------------------------------------------------•----------------------------------- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S e laws, and rules and4relattions of the San Joaquin Local Health District.[Signed} - --- --------- ---- --- ------------------------- Ow and/or Contractor) --- --- -By:--- ---------- ----------(Title)------ --- ----.- --------------- - - -- ------------- --- - (plot plan, showing size of lot, location of system in relation to wells, uildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY l 1717 APPLICATION ACCEPTED BY_. --------------------- DATE------- - �-- - ---- REVIEWEDBY--------------------------------------------------------------------- ---------------- DATE---------------------------------------------------- ------ BUILDING PERMIT ISSUED------------- ------------------ ------ DATE-------------------------- ---------------------------------- I Alterations and/or recommendations------ - ----------- ------------------------------------------------------------------------------------------------------------ ------------ --------------------------------- r , FINAL INSPECTION BY-------- --- -------- I/! ---- ---------------- =, Dafie_ �6 SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California �. Manteca,California Tracy,California F.P.CC.