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FOR 05FICE USE: � 'i ti70 l � I ..= ----------- ------------------ .� 1 fa APPLICATION FOR SANITATION PERMIT Permit No. . ..:---= ------- (Complete in Duplicate) ,3f ------------- -- Date Issued - :---------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Heal}h District for a permit to construct and install the war herein de ibed. This appiication is ma�d,incompliance with County Ordinance No. 549 rZ 76 JOB ADDRESS AND LOCAT�ON _�. Owner's Name-...------- ��►�.. � — Phone... Address--------------- --------.e..-------- - Contractor's Name---------------•------..-..-.:----- --------------------------------------•--------- PhoneInstallation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __I---. Number of bedrooms .- Number of baths _ Lot size ------------- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table'k�?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--------------------I No,�New Construction: Yes p-'l'o ❑ FHA/VA: Yes R No ❑ TYPE 'OF INSTALLATIONAND-SPECIFICATIONS: (No septic tank or cesspool permitted. if public sewer is available within 200,feet.)` Septic Tank: Distance from nearest well_ sJ._-.---_Distance,from,foun_dation---1A:__-----_- ---•-••----------- ...- ®' No. bf compartments------Z----- Size-,lQ.lf-_ -.�------Liquid depth-------�------------ Capacity...l_.Z. - r y Disposal Field: Distance from nearest well.75_--------Distance from foundation. `--------.Distance to nearest lot linye__-,`?_.----_.... �^I Number of lines---.__- Length of each line------ -- -----___----Width of trench-__ -----__ Type of filter material---5_��{.,.��-Depth of_filter material-_---_--/_�-----_.Total length___------J---b-a----------------- Seepage Pit: Distance to nearest well---------------------- from foundation------:.............Distance to nearest lot line---__---__-..---- ' ❑ Number of p;ts__-------------------Lining material----------------------Size: Diameter-------------- --------.Depth-----------------------•-- -- --- Cesspool: Distance from nearest well-_-_------------Distance from foundation--------------------Lining material-------------------------------------- p„ ❑ Size: Diameter------ -----.Depth ----------------------•---- ---------------------Liquid Capacity-------------. ------------gals. Privy: Distance from nearest well_-.-----------------------------------------------Distance from nearest building--------_-._-------------_-__----------_-. t ❑ Distance to nearest lot line--------------- --------------------•------------------------------------------------• ------------------- Remodeling and/or repairing (describe): ----- =-----------------------------•--------•------------••--- ------------....-- ---•----- --------- -----••--------------------------------------------•----------------•----------•------------------------------------.-------.------- •-----------•----••-------------------....... ------ -------------------------------------------------------------------------------------------------------•----------•-------•---------------------------•---------------•-------- ------ I hereby certify that I haveprepared 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. (Signed) ------------------------------------------------------------------(Owner and/or Contractor) _._. =::" a _'""'..=. __::...... - " --------`-.i.-------(Ti+le) By:- -- _ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEF ENT 4SE ONLY / APPLICATION ACCEPTED BY-------- -- - -r-.-- _-- -o- _-- -- 't •c - -------- ATE----- f�� ` ' ------------------ REVIEWEDBY-------------------------- - --------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED---------------------------------- ----------------------------------- DATE------------------------------------------------------------ Alterations and/or recommendations::_:------ --------------------------------------------------------- ------------------------------------------------------- ---------------------------------- ---------------------------------------------------------------------------------- ------------------I----------------------------- FINAL INSPECTION BY:.. r- '2�LL2iyc Date-----�-SAN JOAQUIN LOCAL HEALTH DISTRICT 730 South American Street 3oo Wert Oak Street 124 Sycamore Street 205 Wert 9Th Street Stockton,California Lodi,California Manteca,California Tracy,California E6.9 ArV19E0 6-59 r.P.0 D.SM 6.6d