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i FOR OFFICE USE: / �� APPLICATION FOR SANITATION PERMIT Permit No. _. .....____ f1l_-- 5"t --- -- -------------- ',-A _ ----------------------------------- (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. .r JOBADDRESS AND WLATIO _.. `--------------- -------------------------------------------------------- ----------------------------- Owner's Name _ --P--h--o--ne --- -- - --- - - ------------------------------------------------------ - - i --------------- Address_.....- - Contractor's Name .. - --------------- Phone.. -, --------------------- ------- Installation will serve: Residence Kpartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _I__ Number of bedrooms __Z' f_ umber of baths _/--- Lot size ___. "� 1�(�...✓------------------------- Water Supply: Public system Community system ElPrivate F-1Depth to Wafter Table 46LO ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe (P--`Hardpan ❑ Previous Application Made: (if yes,date-----------------_) No P New Construction: Yes ❑ No [P---FHA/VA: Yes ❑ No j9. TYPE OF INSTALLATION AND SPECIFICATIONS: . (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sep ic TaTik: , Distance from nearest well-----------------Distance from foundation__._____-___._.___. Material___....____._.._ __.__.__. .&F�kjSft49 No. of compartments- ------------------------Size----------------------z---------Liquid depth-------------------------Capacity------- --------------- Disposal Field:, Distance from nearest well------- Distance from foundation__/_/AA_ ------Distance to nearest 1 t�line.-a�P_�-__ Jkd�'fi Number of lines_-_____ _ _h Length of each line___-_.' � Width of trench____ ----------------------------- 0, _____________.__..._------- _ Type of filter materia/j A_ ---Depth of filter material___jj��--� / Total length__.___ �__r______________1.---- r �S Seepage Pit: Distance to nearest well------- _-_.Distance from foundation---- --------- is rare to nearW��e_ 0 �� Number of its.-.- -_ -Linin material_ _.Size: Diameter. -----Dept p 9 Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-----------------._._._.------__._._ ❑ Size: Diameter------ -----------------------------Dept h------------- ------------------------------ ------Liquid Capacity- ---------------------- -.-gals. Privy: Distance from nearest well________- --------------------------------------Distance from nearest building-----.---------------------------------- ❑ Distance to nearest lot line------------------- ---- ------ -------------------------------------------------- -------------------------- - 1 Remodeling and/or repairing (describe--------------- r/---amu=-- -- - ------ ------------------------------------------------------------- 0 ---------------------------------------------------------------- ------------------------------------------------------------ --------------- J ----------------------------------------------------------------------------------------------------------------------------------•-------------------------------------------------- ------------------------------------ ----- --------------------------------------------------------------------------------------------------------- ------------------------------------------- ----------- I 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)----------------------------------------------------------------------------------------------------------------------------------------- ------------------------{Owner and/or Contractor) By--------------- ---------- -- ------------------------- -- Title - -------------------------- - - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- ------------------------------------------ DATE ` �__'4__�----� REVIEWEDBY------------------------------------ ------------------ --------------------- ------------------- ----------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED----------------------------- ----- DATE---------------------------- Alterations and/or recommendations:___,;F _ - G � ------- ------------------------------------------------------------------------------------- ---------------------- -----------------------------------------------------•------------- -- ----------------------------------- ---------------------------------- -------------------------------•-------------------------------- ------------------------------------------- -------------------------------------- -- ---------------- -------- ------------------- ----------------------------- --------- ------------------------------------------------------- ---------------------- ------------ -------- - ------- ----------------- --- ---------------------------------------------- --------------- FINAL INSPECTION BY:-_,� �r__ ✓5-- – Date �-------- Cr2� f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Has:elton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California