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FOR OFFICE USE: r ......... ...... ....... ------------------------------- - APPICATI�N FOR SANITATION PERMIT Permit No. .a� � (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. JOB ADDRESS AND LOCATION `3✓ � ---•- Owner's Name r Phone ... i. ------------ -------------------- Address-------- = _ _ -- -------------------------------------- -------------------------------------------------- �� J1 Phone----------------------------------- Contractor's Name- ------ -- - r Installation will serve: Residence wAparfment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other v Number of living units: .-... Number of bedrooms--3- Number of baths ... `Lot size -- -------- Water Supply: Public systemommunity system ❑ Private ❑ Depth to Water Table�r7ft. Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe'❑ Hardpan ❑ Previous Application Made:= (If yes,date----------------= --) No New Construction: Yes �o El FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Dis$ance from fo ndati n �'_��" - Septic T k- Distance from nearest well-- ... - """ -- -. Ca acit /rF_-L=_ No. of;compartments....--- - Size.- f v" .Liquid depth....------ p Y {� ---------- Disposal Field: Distance from nearest well-----------------.Distance from foundation--------------------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------------------------------------------ 'Distance -------------------------------------"-- \(1 Seepage Pit: Distance to nearest well--- --------Distance from,foundation--------------------Distance to nearest lot line-"--..._.-.-.-.- [,, ❑ Number of pits---- - --------------Lining material-----------------------Size: Diameter-------------- ---- ---Depth-------- ---------------------- ��II Cesspool: Distance from nearest well-----------------Distance from foundation---------------.__-Lining material-----------------"- --------------als. ❑ -Liquid Capacity------------ ------ 9 Size: Diameter--- ----------- ----------- -Depth. - ---.----------------------------------- ------ Privy: Distance from nearest well------------._.-----_------------------------_Distance from nearest building.---------------------------------- Distance -.... ❑ to nearest lot line- ------------ ---------- - -------- ----------------- -----�-------------- ---------------------------- ------------------ - --- - ' _77 F .--"".-- -- Remodeling and/or repairing (describe):--------- �-- 4 i= --------- --------------- ------------- ------------------------- ------------------ . -- ---�,� — L-------- ``--- ------------- ---------------------------------------------------------------- - - ---------- -- ---- ------------------- --------- ----------------------------------------------------------- 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_Sap Joaquin Local Health District. (Signed) - (Owner and/or Contractor) q- -;- � tra or� - ----------------- ------------------------------------- ---------------------------- (Title)------------- ----------------- ---]-------- --------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side FOR DEPARTMENT USE ONLY a �= - DATE l j APPLICATION ACCEPTED BY-------- - -------------- � REVIEWED BY------------------1---------------------- ------------ ------------------------ ----------- ------------------------- DATE BUILDING PERMIT ISSUED------------------------- ------------ —— DATE----------------------------------- ------------------------ k Alterations and/or recommendations------------------- -------------------------- -------------------•------•------------•------"---- -•-------- ----------------------------------------------- ----------------- ----------------------------------- ----------------------------- ------------------------- "---•------- ------------------------------------ ------------------------ - r FINAL INSPECTION BY:-- ---------- Date------- - ` � �"----- -------------- ------ - SAN,JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.120.