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FOR OFFICE USE: ------------- ----------------- �, 3� - APPLICATIQN FOR SANITATION PERMIT Permit No. ___ __ __ ________ --------------------------------------------------------- / ------------- ------------ ---------- (Complete in Duplicate) Date Issued -- �s-� _ _________________ This Permit Expires 1 Year From Date Issue 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 madtr in coliance with County Ordinance No. 549. r JOB ADDRESS AND LO ON _�13. 1 /� 5 -._Lh_/ -S'/- � <` Owner's Name_ r1tfTs ------ Phone--•----•------------------------•- Address---- Contractor's Name- -__ ti"- ------ -------------------------------------------- Phone...-------------------------------- Installation will serve: Residence Zjllkpartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/__ Number of bedroom_. Number of baths -- Lot size - --------------------------- Water Supply: Public system ❑ Community system ❑ Private [j-'15epth to Water Table _Z49ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam lay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made. (If yes,date_.-_-----..--..-_.) No ®/ New Construction: Yes ®/No ❑ FHA/VA: Yes ZJ,--"o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest we __c2,049__Distance from.{foun datio¢,_� _"--.___Mater�al_ �' , uicl de th---�f-------------Capacitv.P_A�-?----- C l No. of compartments------------------------�Size_ --- -- - ' R .44 Disposal Field: Distance from neare t weR__ -_Distance from foundation�10--------�-Distance to nearest lot linea___.__._. Number of lines -------._. _ Length of each line----00., _..Width of tr c .. �ii - ----------------- -------------- �i Type of filter material_�� /5'_Depth of filter material_ �---_._Total leng .1-A Seepage --------------.- Seepage Pit: Distance to nearest well----------------------Distance from foundation-_---_------_-._--.Distance to o line-_.---_.--_-__.-- (fit ❑ Number of pits--- ------------------Lining material---------- ------ ----.Size: Diameter-- --------------------Depth--------- ----------------------- Cesspool: Distance from nearest well---------- ------Distance from foundation------------------- Lining material-----_._-.-----_-.-_--__-----_-- 1 l ED Size: Diameter- ---------------- -- ----------------Depth-------------- ----------- ----------Liquid Capacity--- ------------------------gals. q Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------------------------- ❑ Distance to nearest lot line-------- .- - - --------- -------------------- - -------------------- --- ------------ ------- � ---------------------------------------------------------- Remodeling and/or repairing (describe):---------.�ai'2 �r.�I- ------------------------------------------------------- --- --- ---- --------------- ------------------- ------------ ----------------------------••----- -------------------- ------------- -------------- ------- -------------------------------- --------------------------- 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, pnd rules and regulations of the San Joaquin Local Health District. � � lor Contractor) (Signed)--------- --------- ----------- -------- ------------------------------------ -- -- - ------------------------ -- - -------- -------- -- ---- --- - (Plot plan, showing size of lot, location of system in ion to wells, buildings, etc., can be placed on reverse side). _ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-..-- ------------------- DATE--,?. r-..---------------------------- REVIEWEDBY----------------------------------------------------------------------- DATE_----------------------------------------------------- BUILDINGPERMIT ISSUED-------------------------------- -------------- DATE------------------------------------------------------------ Alterations and/or recommendations----------- ----------------------------------- ---------- --------------------------------------------------------------- FINAL INSPECTION BY:..�'' Y 7- -"------------- Date_. ------ r SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Hazellon Ave. 300 West oak Street 124 Sycamore Street 205 West 9th Street Stocklon,California Lodi,California LL Manteca,California Tracy,California F.P.CU. �`''