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FOROFFICEUSE: , ------------------------------------ 0---------------- APPLICATION FOR SANITATION PERMIT Permit No. .... .. ---------------------- (Complete in Duplicate) Z ''•" ---- --------------- This Permit Expires 1 Year From Date Issued 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 A LO ATIONp.�....r f e ........... d +�_/.__©__t1_.... Owner's Name Irl./_L .d1 / t� � `C 9 6�-- Phone.. .'L!7__ a ----- [D/ Address �O--L--------� -----------------------------------------------------------------------/----------------•-- Contractor's ------------------------------------------•--_--- Phone-..70/f...4 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other El ti�C.c Number of living units: j_�umber of bedrooms __ 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 ❑ 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 is available within 200 feet.) Septic Tank: Distance from nearest well_Ash •Distance_ o� from updation____ __---------Material........ --`. No. of com artments. _ ___----__Size, Liquid clep�h /- Capacity....6�iG ------ _ 1_ __... os led- Distance from nearest well.- _i* _Distance from foundation....1'.1�-----___.Distance to nearest lot line_____ji „ _ d� Number of lines.__________ ___________ _ Length of each line_____ __ .____.___.��_.._.Width of trench��+. ......_ Type of filter material. _ 4____Depth of filter material....../8_____.....Total length___________________ ....._.............. Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line................. ❑ Number of pits______________________Lining material.......................Size: Diameter-----------------------Depth........................_........ C\) Cesspool: Distance from nearest well-----------------Distance from foundation-------------_------Lining material...___............................... C.\J ❑ Size: Diameter--------------------------------------Depth---------------------------------------•------------Liquid Capacity............................gals. C-4 Privy: Distance from nearest well--------------_---------_-------------____----___Distance from nearest building.......................................... ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe) -- ---------------------------------- ------------------- ------------------•------•---•-------------------•---------------- -•----------•---•--------------•------- ----- - -�-- --------------------- , j -------------------------------•--•------------------------------- ------------------------------ -----------------------------•. -• �c.•�.-..� {--------------------------------------------------- ---------- ------------------------------------------------------------------------------------------------------ -----------•---------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, a I s, and rules and regulations of the San Joaquin Local Health District. _ J (Signed) ---- CULContractor) BY: • r .0_. ........(Title) ----------------------- ---------------- ------....... (Plot plan, showing size of lot, location of system in relation to w , buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY. 24, --- - --- -- ----------------------------------------- DATE---.... —-------------------------- REVIEWEDBY-------------------------------------------------------- ------------------------------------------------------------------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED---------------------------------- ------------------------------------------------------------------ DATE------------------------------------------------------------- Alterationsand/or recommendations-------------------------------------------------------------------------------------------------•---------------------•--------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---------------- ----------------------------------------------------------------------------------------------------------------------•---•----------------------------.....---------------•---------------------------------------------- ---•----------------------------------------------------------------------------------------------------------------------------------------------------- -................------------ ------------------------------- ----------------------------------------- -- ----------------------------- ------- ---------------------------------------------------- ----- ------------------------------------------•-----•-- FINAL INSPECTION BY:.(/Z_.f x.-W_ - ----.-- ----- Date---------LF SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Strout 300 Wort Oak Strout 124 Sycamore Street 205 West 9th Street Stockton,California LOd J� f,California Manteca,Cat forma Tracy,California CIL ES 9 REVISED 8-99 2M 5•61 ATLA9 (/ n/ `�VL _ d��i