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FOR OFFICE USE: ----------------------------------- --------------------- APPLICATION FOR SANITATION PERMIT Permit No. ..c _Q g- - ------------------------------------------------------ (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. �J. 0 23- O,�a --l7 JOB ADDRESS AND CATION' 1 } (-`• �`l�-_�- ,,� l`�f �' � Owner'sName------ @�y _... _+ �� Phone 'L �:--------------------------- Address ----------------------------------- Contractor's Name--------------%;: -'----------------------•-------------------------------------•----------------------------------------------"- Phone-------------------------_-------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Mot I El Other ❑ Number of living units: -------- Number of bedrooms ________ Number of baths 9_-P Lot size ____-_ CS_ _ ____'_______________ ____ 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 El Adobe El Hardpan Previous Application Made: (If yes,date_�--' -) No ❑ New Construction: Yes KNo ❑ FHA/VA: Yes ❑ No — TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if publ'c sew?r is available within 200 feet.) � �-. &� /s Septic Ta Distance from nearest well-_______________Distance from foundation__._ _ ___.._.Materjl ��___ ;_________- lx .... Li uid de th__ -__._ -"_.1.4_-._Ca acit - No. of compartments-- S r _ 9 Capacity J Disposa Field: Distance from nearest well r.&'� Distance from foundation_-/Q-----------Distance to nearest lot linep��lr"-,jv Number of lines------------------- -----------Length of each line-----------j "-- -----.Width of trench.---------------------------------- Type of filter material�lyy _�Nt_&Depth of filter material---- --------- ------ otal length___-_,__.________________________________ y Seepage Pit: Distance to nearest vAet1 -------'--Distance from foundation_ '_� Distance to nearest lot r VNumber of pits--"--------! "- ---Lining material_ �.�ize: Diameter._-_ ---7......Depth---------r-/----------- Cesspool: Distance from nearest well-----------------Distance from foundation-----.--------------Lining material---_---------------------------------. El Size: Diameter"-------------------- ---------------Depth------------- ------------------------------------"Liquid Capacity----------------------------gals. 00 . PO Privy: Distance from nearest well-______________________---_"__--- "-____."_"_Distance from nearest building------------------------------------------ ( ❑ Distance fo nearest lot line--------------------------------------------------------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe}---------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------•--------------------------------------------------------------------------------------------------------------------------------- -"----- - F -----------------•----------------------------------------•-------------------••---------------•-----------------------------------------------------------------------------------------------------------------------------� ---•------------------ --- --- 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 regulations of the San Joaquin Local Health District. (Signed)--- - -- ----- ----------------------------------------- -"----------- --------(Owner and/or Contractor) By:__�-_ . = - ---- -------- ------ - ------------------------------------------------(Title)------------------------ ----------------- -- --------- (Plot plan, showing size of lot, lata on of sys em in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY / APPLICATION ACCEPTED BY-------- --- - ---- - ------------------------------------------------ ------ DATE------ --f r�= i------ ----------------------- REVIEWED BY------------------------------------ - -- ----------I------ ----------------------- ------ DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------- ---------------------------- DATE---------------------------------------------- --------- Alterations and/or recommendations------------------ --------------" ------------ ---•--------------------------------------•-----------•--------------- --------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------- ------------------------------------------------------ ----------- ---"-----------------------------------------------.------------------------------------------------------------------------------------ ------------------------------------ - ------ - ---- ------------------------------------------------------- -------------------------------------------- ------------------------------------------------- ---------------- ----------------- --------------------- -- -------- ---- ----------------"------------------------------------------------- ---------------------•------------------------------------- ---------------------------------------------------------------------------- A<?m FINAL INSPECTION BY:. ---"---------- Date_.. "~L_- --1�!.------- .41 SAN JOAQUIN LOCAL HEALTH DISTRICT 1641 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California