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FOR OFFICE USE: ------- / ---_ Permit No. ... -------------------- APPLICATION FOP SANITATION PERMIT ------------------ �---_ -_-_---------------- (Complete in Duplicate) Date Issued A -"- _____._-_ 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. JOB ADDRESS AND LOC ION---,l-!--- ` _ .......... ----------- -------------------- ---------- Phone' / Owner's Name----------`-_---.--- <<j-----�..-- - - Address �� ' . --------------------------------------------------------------------................. Address ---- - - ---------- ------ Phone. - /S Contractor's Name------------------- - -------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial PrI/Trailer�Court ❑ Motel ❑ Other E]Number of living units: -------- Number of bedrooms -------- Number of baths/"/w-,, aths ._ _. _ o 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 ❑ Adobe[r "Hardpan ❑ Previous Application Made: (If yes,date-------------------) No ❑ New Construction:-Yes 2`No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ,O y� ,2! Septic T k: Distance from nearest well_�G ___--__Distance from foundation__.____ -='-•------.Material__!_-.-- ------------------------------ No. of compartments.._--_- _--_-._.___ y� Ca aat GO Size 'z-}�1 ��--- Liquid depth-----�--- ---- Capac j Dispos�al elcl: Distance from nearest well_,"` "-_-Distance from foundation__�:G..._.__Distance to nearest lot lines---------- E^ Number of lines---------1-..-_.,,��___-__.__Length of each line_.ZQ_.4./---------Width of french__.-_��l_--.________-.-- Type of filter material5��45�'---_-Depth of filter material-,Z-0-------------- length_____ ------------------ Seepage Pit: Distance to nearest well-------_--------_-----Distance from foundation--------------------Distance to nearest lot line_.___._____.__.__ ❑ Number of pits------------------ --Lining material-------- ------------Size: Diameter------ Depth------ ------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- 0Size: Diameter------------------------------------Depth------------------------------ -------------------Liquid Capacity-----------------------•---gals. Q Privy: Distance from nearest well-----_._____-__________________----- ------Distance from nearest building.----.--__.---------------------------- ❑ Distance to nearest lot line-------------- -------------------------------------------------------------------------------- ----------------------•--•------------------ Remodeling and/or repairing (describe):- ----------------• ----------- ----------------------------•---- --•--------------------•------------------------------------------------ --•----------------------------- ----------------------------------------------------------------------------•-------------------------- ---- - --------------------------------------------------------------------------------------------------------------------------------------- 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. o. (O ner and/or Contractor) (Signed)_ -- ---------- --- `/}7 - --- ---- --- -----r---- - a N —..... ... . -..---..------- ` -----------------------------(Title)----- By:--------------------------------------- -- -- -- - -------------------------- --- - - (Plot plan, showing size of lot, location of system in relation o wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------- �,e.r------------------------------------ DATE------.1� . r��'---------------------- - ---=-- - ------ -- - REVIEWEDBY-------------------------------------- ----------------------------------------- --------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED---------------------------------------- ------------------------------------------------------ DATE------------------------------------------------------------ Alterations and/or recommendations-------------------------- ------------------------------------------------------------------------------------------•------------------ ------------------- ------------------------------------------------------------------------------------------------------------ ----------------------------- -.1-------I------------------------------------------------------------ --------------------------- ------------------------------------------------------------------------------------------------- ----------------- -------------------------------------------------------------------------------------------_- FINAL INSPECTION BY:.._-_-.f�� Date----- ------ f� ----------------------------------------------------- �`��-�•' - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CC.