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FOR OFFICE USE: -~d~ -------------- IM' APPLIC TION- FOR SANITATION PERMIT Permit No. -- ---------------J---------------------- --- -------- (Complete in Duplicate) ` - � --� Date Issued 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 Ordinance No. 549. JOB �DDRESS AN LOCATION__ ___�_3___ _ ul / Owners Name-- +r- ------ ------ --------- - Phone _._ Address----•--- -- ----- -- ----------------------------------------------------------------- ContralIctor's Nam --- ------- --- Phone - Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Rq ^Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size ___________________-_.____-.-._--_-____"-___._____._._-_ WaferSupply: Public system ❑ Community system ❑ Private [!t-�epth to Water Table Aa ft. Chara!'fer of soil to a depth of 3feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: (If yes,date.__.--_---_,-------_) No ffr,New Construction: Yes ❑ No jR-**_FHA/VA: Yes ❑ No.E — TYPE TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) SepTank: Distance from nearest well_________________Distance from foundation--------------------Material______.________._______.__.___."____.__-__--_-. No. of comp k depth Capacity �t Disposal ve, / Distance from nearest we115 �i ._..._.Distance from founda ion._- _.________.Distance to nearest lot Gne_________________ ❑ ` Number of liries_______�____. Length of each lin ____________________.Wldth of trench..Ave�,,__..__...___.___Type of filter;material___ F -_Depth of filter materiaLr� ._Q_-...___.Total length______________ ___.______________.__ Seepage Pit: Distance to nearest well_lif_ ___-------Distance rs foundation_l02_._._____.Distance to nearest lot line..... ._____.___ �I[tf Num4�er of pits----I---------------Lining material----- .p--[ -Size: Diameter.._- -- Depth-----� `_-- ------ [ Cesspool: Distance from nearest well-----------------Distance from foundation-------------------_Lining material__ -.---------------__-------------- ` ❑ Size: Diameter-------------------------------------Depth-------------------------------=------------------Liquid CapacitY-.--------------------------gals. Privy❑.I Distance front nearest well-----------------------------------------------.-Distance from nearest building---...__.________.____.__________.F.. \ Distanceto nearest lot line- ----- - -------------------------------------------------------------------------•------------------------- ----------------------- Remodeling -----------------Remodelin and or repairing describe ----------'-I[----------------------------------------------- - IIt III - ---- '1------ ------------------------------------------------------------------------------------------------------------------------------------------------------------- Ihereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, andles and regulation of the San Joaquin Local Health District. II� ; (Signed)------------------------------ - --�-- ---- ---- ----------- -----•--- - ---------------------------------- --------- •-----------------------(Owner and/or Contractor) 11 By------------------- --- --.. ---- - ------------ ----- - ----------=-----------------------------:-----------------(Title)---------------------------------------- ----------------------- (Plot plan, showing si of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). ,gyp 11: FOR DEPARTMENT USE ONLY .I. - APPLICATION ACCEPTED BY----- ------------- e '--- ----------------------------------------------- DATE-------�--- /---- - -- ------•- ---------------- REVIEWEDBY---------------------------•----------------- --------- ----- --------------------------- DATE------------------- -•---------------------------------.--- J BUILDIING PERMIT ISSUED------------------------------------------------------------------------------------- ----------------- DATE------------------------------ --- Alterations and/or recommendations------- ------- - - --- --- --------- -------------------------- ------•-------•-----•----"------•-----•-------------------- ------------------- --------- -------------------•-------------------•-----------------------------------------------------------------------------------------------I-------------- --------------------------------------------------------- 111; ----•----------------------------------•------------•--III; - ---I-i-------------------------------- --------•---------------- ---- -------------------- ------------------- ---------------------------•--"-------•----•---------------•---------- ---------------•----------- --------- 11-----------------------------------------------------------------•---------------------------------------------I---------- -------------- --------- ------------------- -------------------------------- I I . J FINAL INSPECTION BY:.... `...... � - ------ Date `�. �`-.- � , I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy, California I F.P.0 O.