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F R OFFICE USE. . fes _ d `APPLICATION FOR SANITATION PERMIT Permit No. .� .."c'lll �� ---------- ----- --------•--------------------------- (Complete in Duplicate) Date issued _ _______ ___..__. 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. 1 - a S F ,S1C /� JOBADDRESS A LOCATION---:-�_`�_�� -:--------�..---•-•--------------------•--- - -----�------------------------------------------------------ , ------------------------------ ... --------------- - -- --------- Phone Owner's Name----- d �'�r f � Y ----•--------------•-•------------•--- Address--------------------------------- - Contractor's Name Phone Installation will serve: Residenc7""partment House ❑ Commercial .❑ Trailer Court ❑ Motel ❑ Other ❑ r�; f# Number of living units: ---�__. umber of bedrooms -A Number of baths -------- Lot size ----------____x ----/Y=------------------------------ .-\ Water Supply: Public system 29 Community system ❑ Private ❑ Depth to Water Table -------- ft. y Character of soil to a depth of 3 feet:. Sand E] Gravel ❑ S ndy Loam E] Clay Loam ❑ Clay ❑ Adobe W/Hardpan ❑`*�% Previous Application Made: (if yes,date....................} No New Construction: Yes ❑ Noe FHA/VA: Yes ❑ No [ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I S ti an :{ Distance from nearest well_________________Distance from foundation_."""-__---._._.__-Materia ---------------------------------------------.__. No, of compartments-------------------- -----Size.-------------------------------Liquid depth Capacity • Dil T Distance from nearest weft------_---------- Distance from foundation--_.____.______----Distance to nearest lot line--------------- s posal Fiey� iso � k umber of lines----------------- ---- - --------Length of each line------------------------------Width of trench.. ---------.--------- ------- VType of filter material-------------------------Depth of filter material----------------------- length------------------------------------� r .___Distance from foun tion_____ . � i1 t Seepag Pit: Distance to nearest welL_.__I�_I'J__._ �Q .Distance to nearest lot ii e__.__._ Number of pits�l.....f--------,__Lining material_-�s_�ze: Diameter. __ -�...Depth.....,l.d_.'#". ----- Cesspool: Distance from nearest well--------------___Distance from foundation--------------------Lining material-----------------------_----____..._ ❑ Size: Diameter-1--------------------------------- Depth---------- ----------------------------------------.Liquid Capacity------------------------• -gals. Privy: Distance from nearest well---------------------------------------------- --Distance from nearest building------ ---.------------------------- > [] Distance to nearest lot line_______________ " ------ .... Remodeling - --------- - C -- ------ - ---- - -------------•---•-------------------------------- Remodeling and/or repairing (describe):-.-.-------L�. -��df2.�cA�--`-------------� -•--------- ----------------------------- --- --------------------------------- ---------------- - -- -------------------------------------- ------------ --- -- .------ -'------------------------ I ----------------------------------------------------------------------- - -------------------------------------------------------- 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. ! (Sign - ------------ ------------------------------------------------(Owner and/ By:------------------------------------------ -------- --------------------------------------- (Title) (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). f s FOR DEPARTMENT USE ONLY ��yy� DATE---------------(_-0-- ----/__0------gip ------------ APPLICATION ACCEPTED BY--------- X -",----------'- --- ----------- ---- REVI EWED BY--------------------------------- -I ------------ ------------------------------- --------------------------------- DATE------------------------------------------------------------ --------- - BUILDINGPERMIT ISSUED------------ Il---- ---------------- --------------------------------------------------------------- DATE------------------------------------------------------------- Alte�r'ati21 �d/or recomm-endation=s:_ - ... d ------------------------------- - -----"------------"-"-""-------------------------------- ---- ------- 01 r ------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------- "I ----------------------------------------------------------------------------------------- FINAL INSPECTION BY:...------- ------------ Date_..." ms's - SAN JOAQUIN LOCAL HEALTH DISTRICT 4 16o1 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California