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FOR FFiCE USE: APPLICATION FOR SANITATION PERMIT Permit No. ------------------------------------------------------ -- (Complete in Duplicate) bate Issued .3 �s' ' ------------------------------------ -------------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Healfh District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 50. JOBADDRESS AND LOCATIO --------- -------- ---------------------------------------------------------------------•---------• ---------------------------------------- Owner's Name ------• -- -- --------------- -- -- Phone---------------------•- --•---- Address----------------• � � ------ --------------------�✓Lt/-�c-Q.�------------------ ---------•--••��r� .�/�...__.. ------3-- ` = + ----------------- Phone-----... �Q 3 ContractorsName----------- ---=----••--- --------•----------- - -------------------------`-'-$-'----------------------------- �---....--•- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer t PE10"Motel ❑ Other ❑ Number of living units: _ ___ Number of bedrooms -_l_-- Number of baths --/-- Lot size ------ _Q U .. •----------- Water Supply: Public system E] Community system ElPrivate B-�epth to Water Table _ - ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Er""Hardpan ❑ Previous Application Made: (If yes,date--------- --------- ) No [�t'�New Construction: Yes ❑ No FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �w � Septic Tank: Distance from nearest welL_.__.Q______Distance from foundation_ Material.- ._._.___ ________------__________---- [ ' No. of compartments-------c2-..-----� -__Size--3_ .- -------:---Liquid depth----- -------------Capacity---�4a. ----�� Disposal field: Distance from nearest well. . -....Distance from foundation--- ----- Distance to nearest lot line_�_C�_C1____ [ErNumber of lines__..._oz-_____________________Length of each line_S�_.-_- ----.-.Width of trench___--_a_-__`__--------..-- Type of filter materiaDepth of filter material _-Z9__--______Total length-_-._-_._--X04-.(-------------- Seepage Pit: Distance to nearest well_--- ----------------Distance from foundation______-_____.___.Distance to nearest lot line----------------- 7 I [❑ Number of pits------ --- ---- -- ---Lining material----- - - ----------- Size: Diameter------------.- --------Depth--------------------------------- 9 Cesspool: Distance from nearest well-----------------Distance from foundation----------------- - Lining material-__.___...----.._--.._.---_._-.--.--. ❑ Size: Diameter- -- -------------- ----------- ----Depth---------------------------------------------------Liquid Capacity----------------------------gal4 Privy: Distance from nearest well-------------------------------.__.____..._-...Distance from nearest building------._-._--.----.-_--- -_---.----.. ❑ Distance to nearest lot line-- -- ----------------------f--- --------- - ----------------------- Remodeling ---------------------Remodeling and/or repairing (describe)---------- --------------------------- ---------------------------------------------- i A -----•---------•--------------------------•- ------- ------------------------ I ----.---------------------------------------------------------------------------------------------- ------ -----------•------------------------------------- --------------------------•-------------------------- ---- F ' -----------------------------------------------------------------------------------------------------------------.__-----__.,---_•--.-----_------------_---_---------_-____-___----_---_----_-----_-_--_--------..-.__.___.___._ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County s ordinances, StAts laws, and rules and regulations of the San Jqaquin Local Health District. (Signed (Owner and/or Contractor) �Y= -----------------------------------------(Title) (Plot plan, showing size of lot, location of systemlere�lafion to wells, buildings, etc., can be placed o reverse side). FOR DEPARTMENT USE ONLY a APPLICATION ACCEPTED BY- �--- =--7- ---- ------------------------------ DATE-. `'� "" REVIEWEDBY------------------------------------------------------------------ - -------------------------------------- DATE BUILDING PERMIT ISSUED---------------------------------- ----------------------------------------------------------------- DATE Alterationsand/or recommendations:-----------------------------•----------------------------------------------------------- ------------------------------------------------------------------- ----- -------------------- ----------------------------------------- --------------------------- ------- ---- ----------------------------------------------------.---------------------------------------------------------- ----------r------------------------------------------------------- - -------------------- ---------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------------------------------- ---------------- -- Date--- FINAL INSPECTION BY:.- `...� ------------- ----------- ---------- -- - � �...-- --------- --- ------- �r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Fla:elton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California