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FOR OFFICE USE: ------------------------------------------------ -------- --------------------------------------- -- -------------- APPLICATION -- ------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. /y --- -------------------------------------------------------------- {Complete in Duplicate) --------------------------------------- This Permit Expires 1 Year From Date Issued G�� 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. .01?_ 2-ct0,_6/0 JOB ADDRESS AND LOCATION,__?'* __JU __ -----. - --4c --�J- �-w�-� Rd....... _:,` l• C4: Owner's Name •- fL� - ------------------------- ------------------------------------------ Phone--------------------------------- Address-------- ---..__-._-:-------------------Address-------- 4 ----- I _ , Contractor's Name------- •..` ----... ------ Phone------------------------------------ Installation --{- ----------------------- ------------------- Installation will serve: Residence ❑ Apartment House L] Commercial E] Trailer Court F] ❑Motel ❑ Other 4.0�""'— Number of living units: -------- Number of bedrooms _ ___2' Number of baths ___l___ Lot size - __-c7�--'e ------"-��- - -•-- ----------------------------- Water Supply: Public system ❑ Community system ❑ Private e Depth to Water Table _______ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy.Loam [� Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ 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.) _=i Septic nk: Distance from nearest well__.-S'Q 'Dista e fro foundation_____ �_._-_-Material_._. : -------------_ No. of compartments f � ` ' p �----------~'Size- Liquid depth-----f---------------Capacity--- pispasa field: Distance from nearest well-___ , .._Distance from foundation____�. _�_____Distance to nearest lot IineS�__'__�.. _. Number of lines------- _-__.__ ______________Length of each line_____ __:_____._._.Width of french--- Type of filter material___ ,�,W_ p " g 1" _ ___De #h of filter material_____/--q__ ____.__Total length Seepage Pit: Distance to nearest well-_---------------------Distance from foundation-------.----------- Distance to nearest lot line__.______ '--___ ❑ Number of pits----------------------Lining material------------------------Size: Diameter.-----------------------Depth----------------- ---------------- Cesspool: ------------------------ ----Cesspool: Distance from nearest well_________________Distance from foundation------------------- material--------._-___-_--------._______._;.___. ❑ Size: Diameter--------------------------------------------------------Depth------------------------------ ---- ---- ------Liquid Capacity--------------------------<als_- Privy: . Distance from nearest well-------------- ----------------------------------Distance from nearest building------------------------------ ❑ Distance to nearest lot line -------------------------------------------------------------------------- ------------------------------------------ r } Remodeling and/or repairing (describe):__..____ -- ------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------•---------------------- .r r ----------------------------------------- ---------------------------------------------------- -------------------------------.----------------•------------------------ ------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State s, and rules and regulations of the San Joaquin Local Health District. (Signed)-------------- ---'----------------_---- _---- 10WIM and/or Contractor) ----------------- -,a - BY: .... ----- ' =_ fes = = (Title) = �- _- r -, (Plot plan, showing size of lot, location of system in relat�0 to wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_____ DATE____�� ________ _ REVIEWED BY---------6/ --------------------- - ------ - - --- ----- DATE- f �� -------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------- --------------- DATE------------------------------ Alterations and/or recommendations:----------_------------------- - -- --------------------------------------------------------------------------- -------- ------------------------------------------------------------------------------• -----------------------------------------•-------•-- -----•---------------- ------------•----- ----•--------•-------•----------------------------------------------------------------------------------- -----•--------------------------------------------------------------- rr 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 ES 9 REVISED 9-99 3M 3-'63 F.P.CD. f m