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rUKUl-l-Kt: U5E: �--�— -------------------------- ------------------- APPLICATION FOR SANITATION PERMIT Permit No. / -- ------------------------------ ------------ --- --- (Complete in Duplicate) ---- ------ -------------- - --------------- --- This Permit Expires 1 Year From Date Issued Date Issued _------------- Application ---Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This_a ,plication,is madejn,compliance with County Ordinance No. 549: 017_ dQors( JOS ADDRESS AND)_OCArON_: v1`c Owner's Na I , ; `4' "- ---------- --------------- --------- --- Ph one__. Address--- -- ------ --------- - --------------{------- - --- -------------•--------------------------------- t Contractor's Name.- -- ----- - - --- ----- °P �J �/ --------- - Phone_--- L1 r , --o t ❑ Motet ` ----- Installation will will serve: Residence Apartment House ❑ Commercial Trailer Court ❑ Other ❑ I Number of living units: ___-_ ,Number of bedrooms __--r-- Number of baths Y-_ Lot size 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,ldate--------__----------) No ElNew Construction; Yes ElNo EDFHA/VA: Yes El No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: r (No septic-frank or cesspool permitted if public sewer is available within.200 feet.) Septic Tank: Distance from nearest well________________Distance from foundation__-----------------MateriaJ F1 No. of compartments-------------------------Size--------------------- ---------Liquid depth--------------- - -Ca Capacity ----------------- Mspos Field: Distance from nearest well:7-`S4.- _�A.-•Distance_ ,from foundation------1_P__t......Distance to nearest lotNumber of of lines__--_ _____I---------------------Lengthf of each line__-=-.1,0_'_______------.Width of french-____-I-�_- 4SR. ----------------- Type of filter material-------------------------Depth of filter material-------Lf_•�--___---Total length--------E4- -_------------- Seepage it: Distance to nearest '1111_- �OD- _f'---Distance from foundation_:__IR-"-__--=:''Dis��e to nearest lot lire-_._S_�____ Number of pits__ ___ ___________Lining material__.___$:-1.?.-------Size: Diameter __ .,:______Depth------A Cesspool: Distance from nearest _Distance from foundation_-------------------Lining material------------------- Size, Diameter--------*------- -----------'------- Depth-------------------`---------------------- ----------Liquid Capacity------------ ---- -------gals. Privy: Distance from nearest well________ -------------------- --.-----Distance from nearest building-, Distance to nearest lot line__-_______________ ------- --------------------- .� ----------------------- ---------------------------- r Remodeling and/or repairing (descri3be):____ ---------------------------------- --------------------------- --------- ----------------------------------------- - - -- hereby certify that I have prepared --- this application and that fhe work will be done in accordance with San Joaquin County ordinances, State laws, and rules andregulations of the San Joaquin Local Health District. (Signed)----------------- -- ------- - -------- ----------------- --------------------------------- --------------- ------------ - -- -� and/or Contractor] By:------------- ------------------ Tifle - ---- ---- --------- ------------------------------------------------------ { ) (Plot plan, showing size of lot, location of Sys m in rel tion to wells, buildings, etc., can be placed on reverse side). t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_f - REVIEWED BY------------------ -- ----- DATE BUILDING PERMIT ISSUED ----------- DATE__ ------�----------••-- -Alterations and/or recommendaf ions:------- ------------- __________________ ------------------------------------------------------------------- ---------------------------------------------- - -------------------------------------- ------------ ------------------------------------------------------------------------------------------------------------------- ---------- - --. - --- ------ _ FINAL INSPECTION.-BY:. � ---------------- Date Date-------- - -- �� - --------------- ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 F.Na:ellon Ave. t 300 West Oak Street 124 Sycamore Street 205 West 9th Street 1 Stockton,California Lodi,California Manteca,California Tracy,California F F.F.CO. A t � A t