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------------------------------------------------ APPLICATION FOR SANITATION PERMIT Permit No. .. � . ------------- -------------------------- (Complete in Duplicate) __________________________ This Permit Expires 1 Year From Date 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 Ordinance No. 549. 2� JOB ADDRESS AND LOCATION. '� T`J`--t �g--- 2 .3 3 r &,-x- ' / `t � . Owner's Name ,..Qf� Phone 3 S-------------------- �- Address --------------`---------------------------------------------------------------------------------- Contractor's Name--------- - --------------------- Phone �� `J/ Installation will serve: Residence ��Apartment House ❑ Commercial ❑ Trailer Court ❑ /Motel E] Other ❑ Number of living units:/--- Number of bedrooms --3. Number of baths --c;>2- Lot size .-.-1�7_~'a ... ___.................... Water Supply: Public system ❑ Community system ❑ Private Uj'-1Depth to Water Table/0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ San y Loam ❑ Clay Loam ❑ Clay ❑ .Adobe 2"Hardpan ❑ Previous Application Made: (If yes,date____________________) No New Construction: Yes ❑ No �HA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) *ank; Distance from nearest well_________________Distance from foundation-----------_--------Material.__.-_-____--...__._-_-_------_-____-.__________- No. of compartments-------------------------- ze---------•---------------------Liquid dep. -------------------------:Capacity--------------- ` Disposal Field: Distance•from nearest well-_�-U-.--._Distance from foundation----�_ ...._.Distance to nearest lot line_ _._.___.._. ❑� Number of lines----------- _ _Length of each line---,�0_4__--__ ....Width of french..__ .�� Type of filter material-----__'__!.. /, Depth of filter material_-_-9---------- Total length____,ff_ ______________________-- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- El Number of pits______________________Lining material_-_.-. ----------------Size: Diameter.......................Depth--------------------------------- Cesspool: Distance from nearest well_________________Distance from foundation---------------------Lining material--------------------------------- .__..(� ❑ Size: Dia-meter.................----------------------Depth----------------------------------------------------Liquid Capacity............................ga . Privy: Distance from nearest well------------------------------------------------.Distance from nearest building______________--__________________---__ ❑ Distance to nearest lot line-----------------------------------------------------------------------------------------•----------------------------------------- \ Remodeling and/or repairing (describe):-------------------------------------------------------------------------------------------------------------------------- ------------------- ---------- ---•---------•-------------------------•----------------------------------------•---••--------------------•-•--••-----•----•--•------------------------------••--•-•---------------------------------........... c , ----------------------------------•-•--••------------•-------------•---------•---•--------------------------•--------------------------------------------------------- ------------------------------------------- .. . W ---------------•---------------------------------------------•------------------------------------------------------------------------------------------------ ..- - - ----- ----- --- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St laws, and rules and reg tions of the San J quin Local Health District. - ---------- -------------------------- (O er and/or Contractor) (Signed)------ By:--------------------------------- ;r._-. -------- ------(Title)--. - -------- _ ... (Plot plan, showing size of lot, location of system in relation we Is, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY--------------------------------------------------------------- --------- -- --•- . E------�.--- -- -- -------------------------- REVIEWEDBY----------------------------------------------------------------- -- =' -------- ATE - BUILDING PERMIT ISSUED---------------------------- I.. TE_________ _________ Alterations and/or recommendations-------- ---------------------------------------------- -----= j Ey ------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- ----- -------------------------------------- ---------------------------------•--•---•---------- =-------- ----------- ------•------------------------------------ -----------------------------------...---- ---------------------------------------------- T! �' Date /✓ J f FINAL INSPECTION BY-------------------- -------- -•---•.... ---------- 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