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FOR OFF CE USE I _____ ____ __ ____ APPLICATION FOR SANITATION PERMIT "Permit No. ..>. .. '. ._r r --------------------- -- ------------------------- (Complete in Duplicate) ' �►7 f � .... -- This Permit Expires I Year From Date Issued Date issued ___ .... li , 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 compliantw' h�younty Ordinance 549. ADDRESS AND LOCATION JOB AD /� r - � _----------- = f /} Owner's Name (,.. - -=-------=--------'------•---------------------------------------------------------------------- Phone---...---------- --...-- •-•-....-- Addess ............... ...-- , Contractor's Name--------•-- '_. - I Phone Installation will serve: Resident partment House ❑ Commercial ❑ Trailer Court [] Motel ❑ Other 1 Number of living units: . umber of bedrooms . __ Number of.baths __I___ Lot size �._� _�S__3.�'z' ---------------------- Water ________ _Water Supply: Public system Community system ❑ ,Private [r] Dep th to Water Table 47__ ft. Character of soil to a depfIt of 3 feet: Sand ❑ Gravel'EY Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[4-14ardpan ❑ Previous Application Made: (Lf ye's,ddte____________________] No' New Construction: Yes ao ❑ FHA/VA: Yes ❑ No 21— TYPE OF INSTALLATION AND SPECIFICATIONS: 4 `(No septic tank'or.cesspool permitfed if,public sewer is available within 200 feet.),. ' s _ Septic Tank: Distance from nearest well'`:.Distance from foundation__lp.y.._.______.MatariaL-_._ ____ {-------------- [4--� No. of compartments__ --------------------Size------z <' 9___.___Liquid depth_.__.�!______.______Capacit� ----- DisposalField: Distance from nearest well.�^gM�-_-_Disfaance.from foundation...lo."._- Distance to nearest lot line_ssr�_______. Number of lines------------------________ Length of each line___'-___. ___ Width of french.___1y__ CM p g----------------Total length -_---------------------------- Seepage r - Type of filter material_ % __ _ _______De th of filter material -, 4 Seepage Pit: Distance to nearest well_2r_9� -__----Dist nc�-�jom foundation_fD.�±�i..Distance to nearest lot line__ -�x Number of pits--/--- Lining material �0.� ._..Size: Diameter___.3�_4_______Depth_-,__._2�3-________________ 5 Cesspool: Distance from nearest well-----___-----Distance from foundation-------.------------Lining material__-_.______________.________-___-____. 1 ❑ Size: Diameter---- ---------------------------- Depth----------' :: `---------------------•----------Liquid Capacity----•-------•---------------gals. ,F I _ a Privy:! Distance from nearest well_______________________y-.--______-____:..: _Distance from nearest building___-_--___.__________-_•_-_-_.____._____- ❑ Distance to nearest-lot line--------------=----------------=------------------------------•---------------------------------•--•---------------------•------------------- ,s ,,iyt E Remodeling and/or repairin (describe):-- �"' - -----•---•---------- -------------------------•------------------•-•------------------- -----••--------•---------------•---- ------- {�'rt'P - �-- _ �.. _ i -------------------------- --------•--------------•-------•-----------•---•-------•- --------•--------------- ---------------------------------------------------------------------••----------------------- I hereby certify that Ihave prepared this applicati a d that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations oft n Joaquin Local Health District. (Signed) ----- ------- ------ -------------------------------------------------------------------(Owner and/or Contractor) By:---------------------------------------•--------------------- •----- --------------------------------------------------------------(Title)-----------------------------------____ -- _------------ (Plot plan, showing size of lof, location of system in,relation to wells, buildings, efc., can be placed on reverse side). FOR PEPRNT USE ONLY APPLICATION ACCEPTED B - -- - --- - -- -- -------------------------------------- DATE REVIEWED BY------------------------------ ----------'-------------------- DATE BUILDING Alterat ons and/orPERMIT ecomm�recommendations: - ------- --------------------------------------------------------- - ---------` DATE---------------------- ---------------.-••--------•-•---------- - ------- ----=-•-----------_�...-._. _- �-------�------ 7__��.__C��.--._.Cf�.___Bl � �-•---phcinsd_ ;3tas�.__;x �„�„� ------------------------------------------- e---/-- .. - ¢--(`-�--- --� ------------ . eyet /-�V � ------ Y -f-- -- - -6-� - .�_ .� - - �1. FINAL INSPECTION BY:-----f 1 ¢ Date-------- --=- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Mpnteca,Californip Tracy,California E13-9 REVISED 13.99 r.P.Ca.ZM 5.60 d