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FOR OFFICE.USE; - -- - -- --- --- -------------------- -------- _ 7- ------- "- APPLICATION FOR SANITATION PERMIT Permit No. -..� X� 13 ------------ t�S Fo i------3`;" "17 (Complete in Duplicate) " - --------------- 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 AND LOCATION.M---W''-:I- .4 __________ ------------------ ----------------------------- ----------•-------------- �/y� ,, Owner's Name--- .XA ---------- --- - ------ ---------------------- Phone... i T------ .-""""_----------...__---•.----•__.....--•--•---"....."..-•-------•---------_--•----....... • -y Contractors Name".. 7: ---•------ -----------------------=----------- -- -- r -.r Phone...----- Installation will serve: Residence ®Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other ❑ ;Number of living units: --J_.- Number of bedrooms __"2_ Number of baths .J--- Lot size Water Supply: Public system R11-C6mmunity,system ❑ Private ❑ Depth to Water Table ." " ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [4�-fiardpan ❑ Previous Application Made: (If yes,date----------- -----) No E2r--New Construction: Yes [3`-No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 f4et.) Sept Tank. Distance from nearest well""---------------Distance from foundation."----------.-----:.Material-------------- � � No. of compartments Size Liquid depth ------ ---------Capacity-•--------------- D is l f Distance from nearest well.__."------"--------Distance from foundation--------m...........Distance to nearest lot line----------------- Number of lines-----------------------------------Length of each line.------ _---- ---Width of trench-'---...--"__"-- " Type of filter material------------------"------Depth of filter material--------"------------.-Total length--------------.---------------- ------------ pa Seeg Pit: i:' Distance to nearest well!_!" ."_.-_-_ Distance-fr foundation�Q-__r_"......".:Distance to nearest lot Number of pits """" _:.""-" "Lining mafierial , lh�_t'_ ".Size: Diameter--.-- 33 __'"_-____Depth_-___--- --------------------- q� Cesspool: * Distance from nearest well---:--------------Distance from foundation-------------------Lining material----------------"-"-.-----_-.-__." ❑ Size: Diameter---------�_""""""_.__"'i_ Depth.- Liquid Capacity ........-......gals. . Privy: Distance from nearest welf--.:-------"-------------------------------------Distance from nearest building ❑ Distance to nearest lot line--- i 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 reg on of the San Joaquin Local Health District. (Signed) ----- • ------------(Owner and/or Contractor) BY: -- -- - ---- - --'--- (Title))------------------------ (Piot plan, showing size of lot, ocation of system"in relation to wells, buildings, etc., can be placed on reverse side). • ,I OR DEPARTMENT USE ONLY r APPLICATION ACCEPTED BY---------------- ---- --------------------------------•--------------- DATE--------- t REVIEWEDBY--------------------------------------------------------------------------------------- ------------------- DATE_" BUILDING PERMIT ISSUED------------•------------ - ----- ---•----------- DATE.- Alterations and/or recommendations:"-"_"_._, -_ � e____ ......... "--- /`" ----------•------------ ----------------------------------------"----------------------------------------I------ ------------------- J. ---- -•------'-------------------------------------------- ---- ---------------------- FINAL -------- ------FINAL INSPECTION BY--- -------------" / - -^--------� Date- -- --'----- _ SAN InQUIN LOCAL HEALTH DISTRICT 130 South American Streo 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E6.9 REVIDED 9-$9 F.P.CM.2M 6.60 i _