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r FOR OFFICE USE: --------------------------------------------------------- q� PPLICATION FOR SANITATION PERMIT Permit No. ..../.11`.2 --------------------------------------------------------- (Complete in Duplicate) f G G Date Issued _____�.`_/;__._=� _________________________________________________________ I This Permit Expires 1 Year From Date Issued rmlovr Application is hereby made to the San Joaquin Local Health District for a permit to cons ruct and install the work herein described. This application is made in compliance /with County Ordinance No. 549. JOB ADDRESS A LOC ATI lY �(� '`y� 1�C•�- r Owner's Name •---• ••-- . ••-• ------------------------------------------------------------------------------------ Phone--------------- Address --- .-_. . .:-----•--••••. �Lz �'�' -----------•------- -------- -----•--.....---••-......................... Address Name----- ?—.A,- s..r��partment PhoneInstallation will serve: Residence House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .1--- Number of,bedrooms3_-_ Number of baths Lot size ___ ___ __..... _____ -_-___-_____-_ 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 rJ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date----- --------.-----)`No ❑r' New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 1 (No septic tank or cesspool permitted if public sewer is available within 200*feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation..------------------Material------------------------------------............. ❑ No. of compartments------ -----------------Size--------------------------- Liquid dept`-------------------------Capacity---------------------- Dispos fi ,f eld: Distance from nearest well-__�Q._Distance from foundation.. -`11.......Distance to nearest lot line-7__. .___.. Number of lines-------------f--------------------Length of each line-____ P. _!.__ ____.Width of french------------------------------------ '? Type of filter material------SA--------Depth of filter material__.... ¢-__ g ----._.Total length £ Seepage Pit: Distanc to nearest well------`_QD___-.Distance fr�of�'yfo�undation____ _______.Distance to nearest lot line...... of pits.............------Lining material----��_-__Size: Diameter--3 �_._.Depth_._ _. '___________________ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material.__-.--..--______-- _---_____....... ❑ Size: D43meter--------------------------------------Depth--------------------------------- ------------------Liquid Capacity............................gals. Privy: Distance from nearest well_- ---------------------------------------------Distance from nearest building--,_---__---_--__-_••-••-----._-....__-._. ❑ Distance to.nearest lot line------------_------------------ ------------------------------------•----------•-------•-------•-------•--------------••---------•--------- Remodeling and/or repairi g (describe):--- -----------------------------------------•---_..................................... ---------------..................................... ------------•--•••••-•-----•---------...............----------•- ----------------------------------•----------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ - I hereby certify that I ve prepared this application and that the work will be done in accordance with San Joaquin County • ordinances, State laws, les and regulations of the San Joa uin Local Health District. M (Signed)--------------------- •--•• )--------_----------- ------- ----------- or Contractor) By:................ ---- c --- .... -- -- (Plot plan, showing size of I t, location of system in relation to wells, buildings, IS ., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTE BY_____ ------------------------------------------- DATE._� t ----------------- _--- REVIEWED � BY------------------- ------------------------------------------------------------------------------------------------------- DATE PERMITISSUE ..............................................................-...................................... DATE------------------------------------------------------------- Alterationsand/or recomm ndations----------------------------------- -----------------------------------------------------------------------------------------------------------------------•---- ---------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------....................... ----------------------------------------------------------------------------------------------------------------------------------------- .............................................................. ---- ---••- -----•--------------------------------------------------• -------------- ----------------------------------------------------- --------•-----------------•---------- ---•----------------------------------------------- ------------------------------------- ------ -----------------•---------------------------•--------------------------------------------------------•-------------------------------------- -------------------------- FINAL INSPECTION BY:- -C --------------__--- Date d SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave 300 West Oak Street 124 Sycamore Street 205 West 91h street Stockton,California Lodi,California Manteca,California Tracy,California 99 9 REVISED B-59 3M 3-'631 F.P.CD.