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FOR OFF4CE USE: APPLICATION FOR SANITATION PERMIT, Permit No. ----- ----------- ------ -------------------------------- (Complete in Duplicate) `�r� Date Issued �---� ---------------------- This Permit Ex ices 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. Thiapplication is made in compliance with County Ordinance No. S49. Q � ! I JOB ADDRESS AND LOCATION s�l� Phone_ --------------- - ---------------- -- Owner's Name-----11410.. Address--------- 4 ----- .C.�.- ---------- Contractor's Name----_----------------•----- ------ Other ❑ Installation will serve: Residence [� Apartment House ❑ Commercial Trailer Court ❑ Motel ❑ Number of living units: ___�___. Number of be ._______ Number of baths __.-__._ Lot size _____________________ ter Water Supply: Public system 171 Community system C] Private k]oDepth toClayaLoama] ] Clayf❑ Adobe[] Hardpan ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy ❑ Previous Application Made: (if yes date_.-__-___..----_--] No ❑ New Construction: Yes F1 No ElFHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 244 feet.) ______------------------- Septic Tank: Distance from nearest well-----__-_-..__-_Distance from foundation-------------------Material-__________Ca acit -- No. of compartments---- --------------------Size---------------------------- Liquid depth Capacity Disposal Field: Distance from nearest well -- ---- -Distance from f l ne a{�7,5-- ---- ---Width ofttrenchest� '�----------- p ________________Length of each Nj Number of lines___...__I--- _--- 9 � ------Depth of filter material-----�--G�-.......... otal length------7-- ---------------, Type of filter materlal__�_�- --- P f --_-Distance from foundation__.-�_Q_--.----.Distance to nearest lot line_5----------- Seepage Pit: Distance to nearest well___�11_� ---- . _.._. Number of its----- ----------------Lining material _- - Size: Diameter.-----_1�;----------Depth---1f NJ Cesspool: Distance from nearest well-----------------Distance from foundation-..--------- Lining Capacity- - ------ ----------------gals. Dept --------- q P Y ❑ Size: Diameter--------- ------ ------------------ P ` - ----Distance from nearest building----------------------------------------- Privy: Distance from nearest well------------------- -----❑ Distance to nearest lot line--------------------------------------------- -------------------------------- - ---- --- -------- -------- ------ Remodeling and/or repairing (describe):------- ------------------------- ----------------------------------------------------------- ----------- - --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that l have es prepared dthiaIli the San Joaquin the orkHeawill lth District. done n accordance with San Joaquin County ordinances, State laws, andregulations - ------------------------(Owner and/or Contractor) .. -- ---------------- - (Signed)-------a f--(�-�-`--�--'---- - . --- "�- ------- •--� . -------------------------------------------- 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 , �J'� 3 rc DATE---- _'- ------------------------------- APPLICATION ACCEPTED BY----- �',� �� -------- --------- ----- DATE-------- ----- ------------ ------ --- ---------- ---.. REVIEWED BY- ------- ------ --------- --- --- ----- - --- ---- - ----------------------------------- ------------------------------------ ------ ------------ DATE------------------------------ ----------- --------------- BUILDINGPERMIT ISSUED---------------------------------- ------ -------- -------------------------------------•------------- Alterations and/or recommend a ion .___................... - -------------------------- ----------------- -------------------- ------- --- ----- eV w'4 FINAL INSPECTION �l�_� ----------------- BY:.. = ----- - Date---- ------ ----- - - - --- --- --- -- --------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.F,C 13.