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FOR OFFICE USE: APPLICATION FOR SANITATION PERMITQQ Permit No. . 11.l••- __________ __ ___ __ (Complete in Duplicate) --- ----------------- -- ��j - - Date Issued ---------________._____ i 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. � A JOB ADDRESS A LOCATIOc.. -.� j4 Owner's Name- Address ame �./ -------------- Phone---------_----------------------- � - 1I t Address-----••----••--- --- L -----92 ......... ----- -----•. Contractor's Name_-__._-�s,�sct . .. . ............... Phone................................... will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑- Motel ❑ Other ❑ Number of living units: J__-_ Number of bedrooms .3__ Number of baths __ Lot size ________ ------------------------ Water Supply: Public system ❑ Community system ❑ Private e Depth-to Water Table ........ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan Previous Application Made: (If yes,date___________________) No ❑ New Construction: Yes ❑ No ❑ FHA/VA-. Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer isavailable within 200 feet.) Septic Tank: Distance from nearest well.............__.Distance from foundation--------------------Material__-_-.-_-__..-.._-__--._____-----.-_---.____----. ❑ No. of compartments--------------------------Size----- --...Liquid depth--------------------------Capacity---------------- -••--- Disposal Field: Distance from nearest Distance from foundation----!�.a_'-__ Distance to nearest lot line___ ------ [ Number of lines------------/____-__._ c__.-_.-___Length of each line______5-_'-4_'_--_.--__-..Width of trench---------:--__,_____________________ Type of filter material------5K:_i------Depth of filter material------t_-rj-_.`7_:___Totai length------Xjz)__ ______________________ Distance to nearest well-_1 d - ____Distance from foundation___!o.. to nearest lot line-...9---_-___-- Number of pits....../--_----__-__Lining material_____- .---.Size: Depth 01 Cesspool: Distance from nearest well-----------------Distance from foundation___---__--.--...._-.Lining material-----__---___----_--_-__________----•. ❑ Size: Diameter--------------------------- ----------Depth----------------------------------------------------Liquid Capacity--------------------- ------gals. Privy: Distance from nearest well-------------______________________--------------Distance from nearest building--------------__._---___.•.__.- ❑ Distance to nearest lot line--------------------------------- ------------------------------------------------------------------------------------------------ ��» Remodelingand/or repairing (describe):-------------------------------------------------------------------------------------------------••---------------------------------------------•------- -----•-------------------------------------------------- r�}--}-------'-------'- - ---------•-------------•-------------------•-----------•------------------ ------------------------------------------------ ------------------------------------------------------------•-------------•---------------...---------------•--------------------------------. �� ----------------------------------------------------- -----------------------•----------•----------------------------•••------------•-- 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. (Signed)._ ---------- and/or Contractor) ----------------/--�-------- -- - By� -sS/ ---- (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 APPLICATION ACCEPTEDBY_. --------------------------------------------_-_ DATE_./t� l�1---------------- REVIEWEDBY-------------------------------- ------------ ------ DATE---------------------------------------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ Alterationsand/or recommendations---------------------------------------------------------------------------•-------- ---------------------..•..-----•----------------•---•-•-------............. ---------------------------------------------------------------------- --- ------------- --------------------------------- FINAL INSPECTION BYf '✓ '%' - __................... Date__/_b_�=. __'�O.t t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California