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FOR OFFI E U v � - _ _ -- APPLICATION FOR SANITATION PERMIT Permit No. ....... - - ----------- ------------------ -------------------------------------- (Complete in Duplicate) "I This"Permit Expires 1 Year From Date Issued - Date Issued ________________ --------------------------------------------------------- ; Application is hereby made to-'the Sari Joaquin local Health District fora permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND CATION_-- .-b_jt�_-.--o,,C C! ,5 'f f -- -„�t.�f,1�Yu_�..... --f �7/-! •'�:'r� Owner's Name ----- Address � �= '....-- -•-- --------------------------------------------------------- ContrContractor's actor's Name--------------------------- #16 ------------ ------------------------.---. -.-------------------- Phone----.._...._.__.....------ Installation will serve: (Residence Apartment House ❑ Cammercial [] Trailer Court”❑ Motel ❑ Other ❑ � t , Number of living units: j--- Number of bedrooms,-?. i. Number of baths _�.-. Lot size .1��___!3-Q___________________________ I Water Supply: Public system ❑ C#mmunity system ❑ Private ❑ Depth to Water Table,;W. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam (Clay Loarii❑ Clay ❑ Adobe❑ Hardpan ❑ + t Previous Application Made: (If yes,date--------------------) No ❑ _New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available-within 200 feet.) Septic Tank: Distance from nearest well____--:Distance from foundation__. _______.Mate al___ _ _de _ _ _ _____________ [[� No. of comparfinenfs.__. - Size.��_�r�`__-�,__.Liquid depth__�!_�__ _/.--__.-._-Capacity___��Q.... Disposal Field: Distance.from neares weil.�__ Distance from foundation- Z .. to nearest lot ®/' Number of lines---___ r_. ___--------Length of each of tranch__,2__--______________________ Type of filter maferial_/__;;-f/_*[4Depth of filter material/If�---_____ Total length---X,Z�---___________________ Seeps Pit: Distance to nearest well---------------------Distance from foundation------.-------------Distance to nearest lot line____•___--_-__-- `f Number.of pits.---i----------------Lining material:___- ------.....--.Size: Diameter------------------------Depth--------------------------------- Cesspool: Distance fromnearest well----___•-_-------Distance from foundation__.______ _ -Liningm. ateria1_._1 __ ,_ ___________________________- Sizer Diameter--------------=-----------.-.--.-----..Depth---------------------------- ------------Li'Liquid-Capacify-. gals. t 'Priv Distance from-nearest well -------Distance from nearest building------------------------------------- --- ❑ � _ - ------------------------------------------------ Distance to nearest lot line-------------------------------.---- --- ,.--------------•----•• -•------------------- - Remodeling and/or repalri g. (describe)=-------- ----- - - ----- = ---••. i E ------------------------------------------------------••-------------------------------------------------------------------- f 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 andire ulations of the San Joaquin Local Health District. R (Signed)----------------------------------- = -- {o_WUD�W Contractor) ...- ------------- �- ----(Title)---- By , .. (Piot plan, showing size of lot, location of system i r ation to wells, buildings, etc., can be placed on reverse.side).' FOR DEPARTMENT IJ E ONLY APPLICATfON ACCEPTED BY { --- -- -------- -------- ----- DATE S n -------------------- REVIEWED BY-------------------------------------------- --- .-------.._...----------•--- DATE ----= ._...------. ------------------------------- BUILDINGPERMIT ISSUED----------------------------• - ---------•-------------------=-----------------=-----------:.... DATE---------- ------------------------------------•-•-•--------_ Alterations and/or recommendations:--------------------------=---------------------------•-•---------•--------------- -------------------------------------------------------------------- 1 -•---------------•------------------------------------------------•-•-------- ---- -----------------------------•-•-------------------•---•---- -------------------•---•-----------------------•------------------------------- ----------------------------- - 1 ------------------------------ ---------------------------------------------------------------------------------------------- --------------------- ...------------------------------------------------_------- I ( ---- AA _ Date-- ---- s -------- FINAL INSPECTION "BY:......:. ...... .'- ----- -C�-�"`.-"�----- - - �=�----�--------•------ -- I SAN JOAQUIIN LOCAL HEALTH DISTRICT 130 South American Stree --- 4300 West Oak Street` ; 124 Sycamore Street', 205 West 9th Street Stockton,California a� Yu;" Ladl;California i Manteca,California Tracy,California EB-9 REVI6E6 B-59 F.F.GQ•$M 6.60 1 k �