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---.--- APPLICATION FOR4 SANITATION PERMIT Permit No /�` '� (Complete in Duplicate) 1 -------------- ------ ----- This Permit Expires i Year From Date Issued Date Issued i 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 N12. 5 . JOB ADDRESS AND LOCATE N. --___ ____.14 �d r q .7�---------- - - Owner's Name -------- ----------------------------------------- Phone,_-, -- Address----------•----- .---- -•-- �- - - -------•• - ----- -- -- -• "-----------•---- Contractor's Name---- `------- - -- ------ - ------------------------------ Phone.......•---------=-----•---------•- --------- -------- - --- -- Installation will serve: (Reside ce [} Apartment House ❑ Commercial E] Trailer Court ❑ Motel ❑ Other ❑ Number'of living units: _ Number of bedrooms _.f /� " r Number of baths __/__- Lot size /E] : .----- F -------------- Water Supply: Public system Community system E] Private Depth to Water Table ft. ' Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay Loam E] Clay [] Adobe�iardpan E]\V Previous Application Made: (If yes,date------------ - ) No ❑ New Construction: .Yes ❑ No ` [4---PHA/VA: Yes ❑ No E] V TYPE OF INSTALLATION AND SPECIFICATIONS: q� (No septic-tank'or cesspool permitted if,public sewer is available within 200 feet.) �] S p i ank:. -Distance from nearest well---------------- Distance from foundation--------------------Material__---_-----___-.--__- .- ' ------------------------- No. of compartments Size---------- ---------------------Liquid depth------------- Capacity . ' p i fid: Distance from nearest --__---- 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 mater ------------------------ - length--------------- ---- Distance to nearest .well ,( - -------Distant m foundation- a_____ Distance nearest lot line_` Number ofpits--.--t { - Lining material ��,/ --.size: DiameterfQDepth- 4 Cesspool: yBarest well---------------- Distance from foundation--_-----_.___-.- Lining material- _-_-._-__----.__.-. s Privy:El size:Distance Qia titer-n._) ------Depth-- --------------- ----------------------------- Liquid Capacity------ ---- --gals. Privy: Distance from nearest well-- _.- -R� _----------------Distance from nearest building r ,: _ . Disfance'to nearest lot line------------------------• --- --------- ------------ ---------- -----------------------•- ----------------- Remodeling and/or repairing (describe):--- ------------------------------------------------ ------------------------------- .-.-_---___-- ------•-----••------•------------'-----" :7: ------ ------------------------------------- ---- --------------------------------------------------__.-_�,----__-_----.------------------._-----__--_-_--...---_-__---------.--------_---__------------_--__-.-------_'_-----__•.-.-_----------------.-----`---------.----- 1 hereby certify that I have'prepared t ' application and that the work will be done in accordance with San Joaquin County ordinances, laws, nd rulps a regu ons of the San Joaq ' Local Health District. (Signed)--_-_ Y -----�---- -- -------- - -- -(Ow rand/or Contractor) OY:------------------- ---- - --•-- �tle) (Plot plan, showing size of lot, location of system in--r---- ion to w IIs, buildings etc., an be Ic4led on reverse side). ;FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_..._' 3 /b - ------------- DATE------- �- REVIEWED BY ------------------------ ------------------------------ ---------------- ' ------- DATE / -------- BUILDING PERMIT ISSUED--`---- ..,t---------- -- - -- DATE---- - ----------- �----_----------------- ----------- -- ----------------- ---- Alterations and/or recommendations:- ------------------------------ ----------------------------- ------- ------- [ -- ------------------ --------------------------------- ---------------- ---------------------------------------•------------------- p ------------------- /-- f ------------------------------------------ --------------- --------------- - --- ------ - ----------- -------- .. Date_ . FINAL INSPECTION BY:. ,. ----•- - --� �✓{ .M.- -- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hmellon Ave, 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California