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FOR OFFICE YSE. . APPLICATION FOR SANITATION PERMIT Permit No. ............. . . ------------------------- ------ ------------ (CompleteD i n Duplicate) �- P ) Date Issued __.____.�f�/-r'-•- ___ _____ _ ._-_ This Permit Expires I Year From Date Issued r 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 Ordinanc No. ,549. JOB ADDRESS AND LOC TION 37----y-------_-_- ------------------•-----------------------_-- . ... . .............. Owner's Name--6?....----•- { •.--•- Phone....... I Address..-•----..3._?Z9_._.-- `- j- ..... - -._... - ---------.............................................--•-•----- Contractor's Name------ -- .-`SST 5---••-- -•------------------------------------------------•-------- Phone................................... Installation will serve: Residence 2- Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: _A... Number of bedrooms .3--- Number of baths J-&-Lot size ......2--Q--q Water Supply: Public system ❑ Community system ❑ Private [A"TD-epth to Water Table __�`_.�.Q ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Cay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date--------------------) No [T"New Construction: Yes [5'—No E3FHA/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__�p.`._______Material................................................ No. of compartments._-.--9-n -------Liqui depth_--Dikanee to nearest lot liep . Disposal a d: Distance from nearest well:7Jr_____--._-_.Distance from foundation Number of lines___I___a________________________Length of each line----7�------------------Width of trench.__9_ _*---_______.._..___.-_ Type of filter material.__It-________Depth of filter material---7Y_F/_____._Total length____....®-------------------- ______ 1 d - .��.............Distance to nearest lot liine---"�--------- Seepage Pit: Distance to nearest well_.[_-®_______.____Distanc�e m foundation UK Number of its---.i' Linin material..__J, -8�° ____.Size: Diameter_. r 3_~._. Depth__-.___.z!� ------------- Cesspool: Distance from nearest well----------_......Distance from foundation--------------------Lining material-.-___-.-.-___._ ElSize- Diameter---- -----------------------------Depth----------------------------------------------------Liquid Capacity------------•------------••-gals. Privy: Distance from nearest well--------•------------------------------- - - Distance from nearest- building---------------------------------------- ❑ Distance to nearest lot line-------------------------------------------------------------------------------------------------•---------------••------------•--•----------- I'( Remodelingand/or repairing (describe):-----------------------------------------------------------•----------------------------------•--------------------------------......--•---------------- I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County i ordinances, State laws, and rules and regulation f +he San Joaquin Local Health District. ' (Signed)____________________ _-__-__ (Owner and/or Contractor) $y:------------------- ------ ....--- --------- •--------- -----------------•----------- (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... �I_ .... -------- REVIEWEDBY--------•------------------- ----------- ----------- -----------------------------------•------------------------------- DATE--/--------- ._..._..-------.-----_---------_-------- I BUILDING PERMIT ISSUED...._._..•o••---:--.................. �t - ......... -� DATE .. ------------ Alterations and/or/recommendati � � 9 ----- --------------------------------------------------------- ---------------------------------------------------------•------------------------------------------ ..................-------------------------------------------------------------------- I FINAL INSPECTION BY: Date '; /----- -- - - --- - ............. ISAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street I 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California M Lodi,California Manteca,California Tracy,California E8 9 REVISED 8-99 2M 3-dt A7LA9 �