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FOR OFFICE USE: , -�_ -------_--�_;_ ._-_ APPLICATION 'FOR SANITATION PERMIT Permit No. .�..3............... - --------------------------------------------------------- (Complete in Duplicate) _________________ This Permit Expires 1 Year From ©ate 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 Ordina No. K JOB ADDRESS AND T N----1 l L ..: -------------------•---•-----------------------------------------•----- Owner's Name__ _ _ ---- --------- ----Phone--------------------------------- Address ---------------------- ----------------------------••------•--••••--------•-••--•----------------------------•------------------------------.----- Contractor's Name-------`-------------••------ � •--------------- ---------•-- -------------- --------- ----------- ---- Phone----.-..-----------------•-•------- Installation will serve: Residence ® Apartmen# House E] Commercial E] Trailer Court ❑�jMotrel ❑ Other ❑ Number of living units: _!-_ Number of bedrooms --/-. Number of baths ___f__ Lot size ._.. ------ _. -_----______________- Water Supply: Public system ( Community. system ❑ Private ❑ Depth to Water Table _____L_ ft. j Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ®--f`lardlean ❑ !� Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ No [�A/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: r I $ (No septic,fank.or.cesspool permitted if-"ublic sewer is available within 200 fee+.)Septic 7 Distance from nearest weDistanc�e from foundation Mat Pial j �� ------------- No of compartments_-__p�1`_�--------Size_S-(----�-(___:__-Liquid depth___��..........Capacity- A0---------- 0 Field: Distance from nearest well-24ULDisfance from foundation. 6_ Distance to nearest lot line----1-5--------- ®-� Number of lines________ Length of each line_____-�1_--��____.Width of trench------ -'............ Type of filter materia__ _ __� _Depth of filter material___ __ _ --- .Total length_________ _( ____________ __ ___ ` Seepage �: Distance to nearest ell_ _____Distant r m fo ndation___- _____.Distan to nearest lot line----------------- Number of pits------ -----------Lining material_ _6_1f/C--Size: Diameter__-�_3---------- .Depth-----A_'�;------_----------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material______________.____._____-_______-___ ' ❑ Size: Diameter------- ------------------------------Depth---------------------------•------------------------Liquid Capacity-----------•--_----------gals. Privy: Distance from nearest well_______________________-----------------------Distance from nearest building-----------___._______________________.._. ❑ Distance to nearest lot line--------- --•---------------<== -------------------------------•----- -••-•-------------.------•--------•-------------------------=--------- t Remodeling and/or repairing (describe):------- -=---•--------------------------- ----------------I+---•------..-.--- ---••-------•- ------.............................---•--- ' ------------••----------------------- ---------- - . - Y , y 1 % r � ____________________________________________________________________________________...____----._____________________________________.______.-_______________.__-_______-______________________.____._______---- _-- I hereby c tfy at I have prepared this 'application and that the work will be done in accordance with San Joaquin County ordinances, State aw , and rules and regulations of the San Joaquin Local Health District. Signed - ------- ---- --------- ------- -- --- --------------------------------------------- caner and/or Contrac+or) } -------- - / BY; = = i � � - -----------------------(Title)-- ---------- - - - ---------------- Piot plan, showing size of lot, Iota+ion o�s stem in relation to ,PIIS, buildings, etc., can be placed on reverse side). I P g _t Y FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--` ------ ------------------•-------•---------------- DATE-- v �g f-------------------- REVIEWEDBY-------------4----------------------------=-- -----------------------------------------------------------•-----------... DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED-------------------------------------------------=----------------------•---------------------------• DATE------------------------------------------------------------ Alter tions and/or recommenda+ions__ _______ ---------------._:-_ ----------------------------------------I---------------------------------------------------------------------------------------------------------------------------------------------I-------------------------------------- -------------------------------------------------------- ------- - ---------- ------------ ----------------------------------------------------------------_--------------------------------------------- - f FINAL-INSPECTION BY: ----- -------4 -- -- -- ---- --------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American S+reef 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California EB-9 REVIBEO 6.59 F,P,C p.JM 6.66 -