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FOR OFFICE USE: --------------------------------------------------------- --_.----_-.---.-/ .:, _------ APPLICATION FORy SANITATION PERMIT Permit No. __ `3• ----- /�--� (Complete in Duplicate) - � Date Issued .�_�-_�_� 1 _____________________________ _ ] .�__. - 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 Ordice No. 549. _ w, JOB ADDRESS AN LO ON G • G Owner's Name--- - -----`----- - ---- -------• Phone6 1 . - ----------------- p� t �, Address-------------------A-O ------ Contractor's ----Contractor's Name--•- --- ----- ------ -- --- ----- ---••----------- -------- Phone.--•------.--------- Installation will serve: Residence ["Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: /----- Number of bedrooms ___ Number of baths _-_ Lot size tS_. _ Water Supply: Public system /[Community system ❑ Private ❑ Depth to Water Table _Oft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe "ardpan ❑ Previous Application Made:_(If yes,date--------------------) No IQ-"'—New Construction:. Yes 5rf o ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: l (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �� i Septic, Tank: - Distance from nearest well------• �- Distance from foundation______('----------Material_-_____.____. "-- No. of compartments-_-2�-----------------Size_ -t)' __'?_:___Liquid depth...._----- ---____-Capacity_____,70!�_ - Disposal Field: Distance from nearest well.-_`- —--------Distance from foundation-JO_---. _._.Distance to nearest lot . _ - l_i_n_e__d—_-`•_-_�_- Number of lines_-----a� ---Len4th of each line-= p-- ------- ---------Width of french - t �� ____Depth of filter material-1 y -__-__Total length..... �___. Type or,filter,material_____ Seepage 6rr_ Pit: Distance to nearest well, �__-___I_________Distance from foundation__________________ Distance to nearest lot line___________,____. 0 } ❑ Number of pits----------------- ----� Lining material-----------------------Size: Diameter---------,-------------Depth-------__-____-___________----_- N f F Cesspool: Distance from nearest well----- from foundation____________________Lining material_-_-______.___--____-_--_________--_. ❑ i Size: Diameter--- ------- ---------Depth----------------------------------------------------Liquid Capacity-...------------------------gals. Priv Distance from nearest well______ _________ ______Distance from nearest building __ ❑ ► Distance to nearest lot line------ ----r---------- C Remodeling-and/ct'repairing':(de""scribe�:'�" = A -------------- -----•-•-------------------------------- t e 1 ----------------------------------------------------------- ----------------------- -------- ----------------------------------------------------------------------------------------------------------- ------------- ------------------------------- ----------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------- I -q--------- I hereby certify that I ve prepared this application and that the ork will be done in accordance with San Joaquin County ordinances;,State laws, a rules. d-regulations of a SalrJoaquin cal Health District. 1 > (Signed)---- ------------ 4 --------------------- - -- ------------- (Owner and/or Contractor) ------------------------ -------- -- -------- BY---------------------------------------------------------------------'-----------------------•---------- ---------------------------(Title)--------- ---- ------------------------ -------- ---- --------- (Plot plan...Ishowing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIO.N.ACCEPTED.BY___ �5 `� _ DATE........ __ -----------eK es- ----- ---- ---------------------- REVIEWED BY---------------------------------------l��. - ----- ----} - --- DATE BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE---------------------------------------------------- Alterations and/or recommendations;------------------------'--------------------------------------------------------------------------------------------------------------------------------------- t -------------------------------------- --------------------------------------------- 1 ----- ------ FINAL {INSPECTION BY:----_._-_-- '" � r/ ---------- Date--------------- . ___ ___ ____ _______________----------- AN ___-._.___AN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.C C.