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FOR OFFICE USE: l ' ... ce APPLICATION FOR SANITATfON PERMIT Permit No. ..a�. -- ---•• 3 �M-- -- (Complete m Duplicate) Date Issued -- /S�� ----------------- ------------------- .- -- _--------------_-.----------------I.. This Permit Expires 1 Year From Date Issued Application is hereby made'l 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 N 49. kJOB ADDRESS �NDI OC.,TION..--"-� 1 ` --------------------------------------------------------------------- - -Phone------------------------------------Owne. e------------ -3 ------- ------------------------ ---------------------- Address � ---------------------------------------------------------------------------------------------------------------------------•------------------------ IMSContractor's Name------------ •-- --------------------------------------.......Phone----------------------------------- Installation will serve: Residence �V Apartment House E] Commercial ❑ Trailer Court ❑ Motel [3 Other ❑ Number of living units: ----t__ Number.of bedrooms --2—Number of baths/------ Lot size ------.757X-11--------------------------- ----•- °Il: Water Supply: Public system [rcommunity system ❑ Private ❑ Depth to Water Table ---.-U ft. Character of soil to a dep 1M of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date--------------------) No Ef New Construction: Yes [5'lNo ❑ FHA/VA: Yes ❑ No ®r TYPE OF INSTALLATION:AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sept' nkx Distance from nearest well-----------------Distance from foundation---------------------Material--------------_---------------------------- ----- No. o �compartments------------------------ -Size----------- -------------------Liquid de th-------------- - --------Capacity------ ------------- Disposal -- --------Disposal Field: Distance from nearest well__-_-=---------Distance from foundation-JO ------------Distance.to nearest lot line-_� .--.---- II ` ' Width of +reach y---------------------- Number of lines_--- --------------------------Length of each line--.3a-- -_------ . Type of filter material--- --------Depth of filter material-_f-.1r- ----Total length----�Q----------------------------- il Seep a Pit: Distance to nearest well---- -----------Distance -froom foundation-- �?----_.---.Distance to nearest lot I'ine__4>r� -.. i Number of pits....-,_�r------------Lining material---- Size: Diameter------3.- ---`------Depth------------- '-`----------- Cesspool: Distanlpe from nearest well--------------_-Distance from foundation---------------- ---Lining material--.-..-------------------_------:----. ❑ Size: Diameter---- --------------------------------Depth---------------------------------------------------Liquid Capacity----------- --------------gals. 'IM ----Distance from nearest building I Privy: Distance from nearest well------------------------- - ---- g- ----------------------- ---------- - - ------------ ❑ ih Distance to nearest lot line----------------------------------- ------------------ -----------•-------------------------------------- ----------------- --- ."Ii, Remodeling and/or .repairing (describe----------- - ----------------- -----*...---------------------------------------- --------------------- - ------------------------------------- 1� -------------- - G --•-----------------------------------------=------- ------------------------•--------------------------------------------------------------------------------------------------------------------- ------ C I� -----------------------------------------------•------------------------------------------= =-`----------- ------- ------------------------------------------------- ------------ ---------------- ------------------ --------------- I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County F ordinances, State laws, d rules a r gulati ns of the San Joaquin Local Health District. (Signed) ` --------- -------------- ----------------- -------(Owner and/or Contractorl BY:---------------------------l,..... ---------•-•-------------------- ------------------------------------------'--------------------(Title)------------------- -- -- -------------------- ------- (Plot plan, showing size of!lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY I /�.f' APPLICATIONACCEPTED BY-- ---•-- -- --------------- - ------------------ - ------------------------ PATE-------L"--------- --�----- -------------------------- 11 ------ -------- REVIEWED BY------------------- ---- -- - ----------------------------------------------------------- DATE--------------------------------------------------------- - -------------- BUlLDING PERMIT ISSUED -,DATE ------------------------------------------- I - - �--- �`---- --- 1 `=--------------------------------------- Alterations and/or recommendations:--...... I ------------------------------------------------------------------------------------------------------------------------------- ---------------'--------•---------- ----- ---------- ----- ---- -------------- ----------------------------------------- -----------------------------------------=---------- I --------- ---- --------------- --------------------- ------------------------------ --------------------- FINAL .INSPECTION BY:.--------- '.- . Date--------N --------------- ------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT v 1601 E.Haxelton Avo. 300 West Oak Street { 124 Sycamore Street 205 West 9th Street I Stockton,caiifornia Lodi,California Manteca,California Tracy,California .i F.P-CO.