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rUKtR-r-K-t US : -7 S�7----------- --------------------------- ----------- -..____ --------- ; APPLICATION FOR SANITATION PERMIT Permit No. . _ ..7 ---------- -------------- --- -------------------------- (Complete in Duplicate) ------------------------ ---------- ---- i This Permit Expires 1 Year From Date Issued Date Issued .. 4r Application is hereby made to the San Joaquin Local Health District for a permit to construct and insfall the work herein described. This application is made in compliance with County Ordinance No. 549. 1 JOB ADDRESS AN CATION ;-2e-7 : Owner's Name----- } �- Phone -- ----------•---------------------- - ----------------- Address /�� '•� �_e.._ Contractor's Name - -- --------------------------------------- ----- - Phona. - - - --------- Installation will serve: Residence 'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms _.4 Number of baths _L__ Lot size D ` - -------------•------ --- Water Supply: Public system ❑ Community system ❑ Private [Depth to Water TableA/&� 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 22�'SJo ❑ FHA/VA: Yes ®--No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) []� No. of com artmarest well--- _ -_--Distance prom four dation_. ______.Materrialr -!---_-- Septic encs.__ a / p Size '7� _..._---Liquid ciepth__��-�--------Capacity_ e tic an : Distance from ne Disposal� nd: Distance froof m lines nearest well__ 9-,--Distance from foundation_+. _. _...Distance to nearest lotNumf--- 1 ----- ---------- �-- ---- Length of each line----e�-- -- --------.Width of trench-'t of filter mat ria Depth of filter material_ -_ � r Total length-----t. �----•--------------------- Seepage Pit: Distance to nearest well----------------------Distance,from foundation-------------------.Distance to nearest lot line----------------- 0 ❑ Number of pits_-"'---------------Lining material----------------------.Size: Diameter----------------------.Depth--------- ----------------------- Cesspool. ---------------- ----Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------________...____ ❑ Size: Diameter------1------------------------------Depth-------------- ----------------Liquid Capacity----------------------------gals. Privy: Distance from newest well---------- ---------------------------------------Distance from nearest building ❑ Distance to nearest lot line----------- ------ ---------------------------------------------- Remodeling and/or repairing fil (descriGef:---------- - ---------- ------------------------------------•-------------------- ----- ----------- ----- ------------------- --------- -------------------------------------------= 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 4eguiatio of the San Joaquin Local Health District. (Signed)-------------- ------ ----- � Contractor) ------- By:------------------------------------- ' # = r (Title) , -...... (Plot plan, showing size of lot, location of system in rel n to wells, buildings, efc., can be placed"on reverse side). ( FOR DEPARTMENT USE ONLY - t APPLICATION ACCEPTED BY------ . -------------- DATE ----------- REVIEWED BY ` - ----- DATE------------------- BUILDING - ---------------------------------------------------------------------- - -I DING PERMIT ISSUED------------------------------- ----------------------------------------- ---------------------------. DATE--------- --- ` Alterations and/or recommendations---------------- ----- ---------------- --- ------------------------------------------------------------------ -------- -------- ------------- --------------.-------- FINAL INSPECTION BY: Date--- F SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 1300*West Oak Street 124 Sycamore Street 205 West 9th Street I Stockton,California r Lodi,California Manteca,California Tracy,California F,RCO.