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FOR OFFICE USE: Permit No APPLICATION FOR SANITATION2 PERMIT . _2_ --- --------------------- --------------------------- /Zj ---- ---------- -------- (Complete in Duplicate) Date Issued -��----J--- ---r� ---- - -- 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 Ordin nce No. ------------------------ 5 JOB ADDRESS AND LOCATION IT E --- -- - ------- --------- --------------------•---------------- -------------------- Name-------------- ----------- --------- ------------------ - -------------------------------------------- Owner'sPhone--- Address--------------, -------•-------•---------e--•-------------------------------- Contractor's Name----------- --t--/j ----- ----- -----------=- ------------ --- ---.. Phone----------------------•----------- Contractor's Lam--- - - ----- -- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1-___ Number of bedrooms _L___ Number of baths ___ " Lot size ___._.` "-- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand FA-dobeGravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑/ -H rdpan F] ty Previous Application Made: (If yes,date____________________) No ❑ New Construction: Yes-E] No ElFNA/VA: Yes ❑ No ❑ ` TYPE OF INSTALLATION AND SPECIFICATIONS: No septic tank or cesspool permitted if public sewer is,available-withi�00_feet.] \` Iarest'well— nte from�fo ndation__._.____6terial --------------------------- Septic Tank: Distance from-aeD V i Size - Li uid depth--------------- ---------Capacity----i---------------- ❑ No. of corn partments------------------------ --- q '~ Distance frortE foundation's/lam----.--Distance to nearest lot line"____________._ ! Disposj�Field: Distance from nearest w I____..._ �.� Width Number of lines----------- Length of f a htline �_,__.Td-------------- of trench----��^_----------------- ------------- Type of filter material_----------- Le p th o ea F material__ ----------------Total length------------------------------------- f Seepage Pit: Distance to nearest well------------_----- from foundation_+_.�_' ---.Distance to nearest oline,__"__s____-_. ...f-Lining material----- --- --Size:'Diameter_- ---------Deptn__--_-- ---- --'------------ Number ----• Number of pits_'::_: - s Cesspool: Distance from nearest well_-______.__Distanceo�furida}'ions' -Linin.g�material____.-.______-__.__E__________.___. ❑ I Depth =._ --------- --- Liquid Capacity ' gals. Size: Diameter---------------------------- t t Distance from nearest b6ildin � C� I---------- Privy: Distance from nearest well------- "------ --------------- - ------------ g Distance to nearest•lot-116e------ ------ -------------------- ------- - --------------------------------------------� - '- --------------- ---- - ------------- ❑ t i ." ------t-------------- Remodeling and/or repairing (descr'sbe):__._--- -- --------------------------------------------------- a _______ �__".__ __T _ ------------- ---------------------------- --------- N,: �- ------------------------- ---------------- ----------- �-�-------- -------=��`'-�"-`-- ``'' _ ------------ ----- ----- --•-�------------�:_---. ------------- --------------------------------------- --------------- I I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin.County t ordinances, Stat laws, and rul a regulations of the' San Joaquin Local Health District. a K A -------:----(Owner and/or Contractor) [Signed) --------1 - t 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). O DEPARTMENT USE ONLY I' APPLICATION ACCEPTED ------------------- DATE-- -J-_A/`.-�_--------------------------- --- BY-__.- � � - - -- -- ---------- ------------- - DATE------ ----------------------------------------------------- REVIEWED BY--------------------------7----- = BUILDING PERMIT ISSUED----- I-------------------- ------------ - - - - DATE Alterations and/or recommendations------------------ --------------------------�-°"------------------------------------------------- ---- ------------------------- t `. ------------------------ -----------=------------------------- ------------------- ----------- ---------------------------------------------------------- ------- ---------------------------------- R ------------------------------------------------------------a --------------------------- ----------- -- w»-:.. ---- -------------- "----- --- ------ - FINAL INSPECTION BY: --- Dated - ---- ------------- -------------------------- If -, SAN J AQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. + 300 West Oak Street 124 sycamore Street: 205 West 9th Street Stockton,California Lodi,California Manteca,California t Tracy,California I ;