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OR OFFICE USE: - 3V .� ------------------- -q--- 'fib _/• APPLICATION FOR SANITATION PERMt'T Permit ,�o. ._. _CZ. . (Complete in Duplicate) iD ----------------- This Permit Expires 1 Year From Date Issued ��, Date issued pplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. his application is made in compliance with County Ordinance No. 549. JOBADDRESS AND LOCATION--- ` •5--, 0' ..--- • ------_-- .........................•......--------------------•-•---....------. Owner's Name---•--•-•--�1----•--- ............---------------------------............ Phone-, vra. 3 2 p 11 Address - ..._..._ .,ct.�... ./'il - ....._.. Phone.y�r `g.�2 ContractorsName....... - --_-••---•- ......................................----••---- {' Installation will serve: Residence [k Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel 0 Other ❑` Number of living units: ._ Number of bedrooms --a- Number of baths ...k Lot size .__._Z!•--•--40-4---------------------- Water Supply: Public system ( Community system ❑ Private ❑ 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,dote....................) No;' New Construction: Yes ❑ No EV 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........_-----------Material---------------------------------------------•--. ❑ No. of compartments-------------- -----------Size................................Liquid depth..........................Capacity---.....- --------- Disposal Field: Distance from nearest well.................Distance from foundation-_-.__..-__-___----.Distance to nearest lot line................. ❑ Number of lines.............--- ...----.---------Length of each line.................._-----------Width of trench.................................... \n Type of filter material----------------------_Depth of filter material-----------------------Total length----------------------------------.____--- V1 i Seepage Pit: Distance to nearest well.... ©r._Distance fr m f ndation..�C�_.�.....Distance to nearest lot line.... T Number of its.-.---._ ._. Linin material.. .___.__-- �.__.Depth_-..—As-_�.__.._--__- p �•--_____- g ,� .__.-..-Size: Diameter__.s��__.. Cesspool: Distance from nearest well---------------•-Distance from foundation._----_-_.-_-_-__.-Lining material-_-_-_-..--.-----.-_.--..-.---_----•- 1 ❑ Size: Diameter......................................Depth......... .-•.......................................Liquid Capacity----•---........------.....gals. Civ r'rivy: Distance from nearest well-------------------------------------------------Distance from nearest building..............__.._-_--.-_-_.-__----_- ❑ Distance to nearest lot line-.------ ---------•-------------- -------------------------------------------------------------------------------- ..................... Remodelingand/or repairing (describe):--------•--•............................................................................................................................................. ..........................- ----- -----------•--- -•---•-•---........----•--......................................................................................................................................... .............. ..•----- •-•----••-•---•-------•-----........_._........--•--............................. ---------....................................--..................-------•------•---------•-- -----•-------- 1 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 and regulations of the San Joaquin Local Health District. (Signed.................... ..........__.._............_ �yyst,, (Owner and/or Contractor) By: ---.� ---------------------------------------------- (rtle)------_--------......-----------------.. .. -------------- (Plot plan, showing size of lot, location elation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.--------- '---------------•----------••---•----------.-.--•----- ------ DATE-- r -1 Ste_................._.....---- REVIEWEDBY------------------------------------------------------------------ ••------••--•---- DATE...............-------------------------------------------- BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE-------------------------------------------............ Alterationsand/or recommendations:................-...................................................................................................-------------.......................... ate............i'..............•---•----.....------------.......--•-•-••••••-•---•............_.....••--•-•--•----...---.._..........---•--•-••--•--••----•- ---•---------------------------------------------------------------------------•--•-------.......-------------------------------------------..-......................... ------•--------...................••...... ------------------------------------------ .................................--•---------- ..............-----..................................................................................................... ---•----------•--------------------- --•- ....-----------•-•------------........----•--------------••---......--•---------------•-------...-------------•----------•-•----.......------•----•-----._.....-----------------... 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,Callfornia Lodi,California S Manteca,California Tracy,California F.P.CO.