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FOR OFFICE USE: --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. -� ---------------------•--- -- ------------------------ -- (Complete in Duplicate) �r O .._., .:..4]/ ___-_--_.-_..-...--...-_.-.__.__._- _ Date Issued ............... This Permit Expires 1 Year From Date Issued - 6�0--o(a Application is hereby made to the Sen Joaquin Local Heall•h District for a permit to cons+r And installT ork herein described. This application.is made.in compliance.with County Ordinance No. S49. r`/- rr�t�w�4•- -- 1-7) ----------- -JOBAQDRESS`AND LO Owner's Name---------------------------------- ...... --- Phone------------- -- Address ------•-•------�-- Contractor's Name--,##!1_ --------•--•---------- ----_......... Phone---•----_------.----- Installation will serve: Residence„ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ r Number of living units: .1..... Number of bedrooms A--- Number of baths __/____ Lot size ___- _ _ _ _. .,r `�.,. 4 ........... Water Supply: Public system ❑ Community system ❑ Private X Depth to Water Table b.0__ ft. i Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam O� Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ i a Previous Application Made: (If yes,dote--------------------) No [ New Construction: Yes No E] FHA/VA: Yes C] No F1 "TYPE-OF INSTALLATION AND SPECIFICATIONS: (No septic tank or' cesspool permitted if public sewer i vailWii within 2004"1 .) =z Septic Tank: Distance from nearest well.___-__-----Distancg�j from foundation.-I..... .........Ma real...._.....-....-....... ............__..._.. Sill-R. �#° _ ____-Ca aci /A 0! No. of compartments...... ----- ----• ` Liquid depth_.. p tY �, -. N Disposal Field: Distance from nearest well__�.�------.Distance from foundation________________Distance to nearest lot line____ Number of lines ___ Length of each,line____j' __ ____._.__.Width of trench. _ _ _ ----_-__-_______-_--._ •� Type of filter materi __ __ __� Depth of filter-material____ _______7atal length---1____Q_'_________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__.________-___-- ` ❑ Number,of pits_=...__.............Lining material------------------------Size:.Diameter_.---------------------Depth._-.........--_._................ w Cesspool: Distance from nearest well _________________Distance from foundation ___ _..Lining material..-.---------....................... . Size: Diameter---------------- -De th---------------- ---' -------------------------Liquid Capacity............................gals. Privy: Dista a from nearest well--------------------- ___- 'y_--Distance from nearest building_--------------------------.___________--_- ❑ Distance to nearest lot line --------------=--- - --- .........- .......-.......-...-----••--------------------..----------------------------- Remodelingand/or repairing (describe):----------------------------------------------------•-----------------------------------------•------------------------------------------•------------- V, ----------------------------------------------------------------------------•-•---------•--•------••------------------- i ------- ----- ----- - I .hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 1 ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. I <- (Sign�d}_ :...: [Owner and/or Contractor) By: �..__.. r 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---/---`=?7, •• REVIEWEDBY--------------------------------------------- -._------•-------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED---------------------------------------------------------------•------------------------------------- DATE---------------------.....----------------------------------- rAlterations and/or recommenda+ions:------------------------------------- A ---------------------------------•...............----.......-----...----•-....---•- ........_.------------------------------------------------------------.-------•------------------------------••--------•-••------------ , 1 ------------------------------------------------------------------------------------------------------•-- -----•-----------------------------------------------------------•-----------•----•----------------------------- 'I k 1 FINAL INSPECTION BY:-.44, t! -------------•----- Date------�:fZ77.� ----•---•--•------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT ` 130 South American Street 300 West Oak Street 124 sycamore Street 205 West 91h Street Stocktonr California Lod],California Manteca,California Tracy,California ES 9 REVISED B-99 AM 861 ATLAS