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F FOR OFFICE USE: ----------- --- -------------------------------- APPLICATION fOR SANITATION PERMIT Permit No. _. �....._..... ------------ - (Complefa' in Duplicate) This Permit Expires 1 Year From-Date Issued Date Issued 1 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein describe . This application is made in compliance with County Ordinance No. 549. 11� JOB ADDRESS AND LOCATION.. 4 1�.--__� ---------- c r__ 1` ----------------------------- / - Owner's Name---------- ----- ------- ---A-1-1-CO-11------------------------------------------------------------------------ --------- --- Phone------------------------------------ Address-------------------- -- -----------------------•--•-------- Address -- -- -------------------------------------------- -------------------------------------------------•---------------------------------------------------------------------•-•- Contractor's Name 4.1i-._ �]1 ------------------------ Phone--- ------------------------------- Installation will serve: Residence ar--A-lpartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ t Number of living units: __t.--- Number of bedrooms -3--- Number of baths A..__ Lot size ------ ------------------------ Water ---------__-_-_____ .Water Supply: Public system ❑ Community system ®-Irivate ❑ Depth to Water Table .4-Oft. F [ A Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeMI Hardpan ❑` t Previous Application Made: (If yes,date......... ..--- ----) No ❑ New Construction: Yes ❑ No FHA/VA: Yes ❑ No TYPE 'OF INSTALLATION AND SPECIFICATIONS: t �, (No septic tank or cesspool permitted if public sewer is available within 280 feet.) Septic ank: -- Distance from nearest well-----------------Distance from foundation--------------------Material---------------.-___.-------------------------__. No of compartments-------------------- .....Size--------------------------------Liquid dep k--------------- ----------Capacity------------------- - 1 Dispos Field Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line----------------- Nu.mber ---__---_-.----.Number of lines---------------------=----_-_-- Length of each line------------------------.---_-Width of trench----------------------------------- 1 ii�xll Type of filter material-------------------------Depth of filter material ---_---._.---..-------Total length------------------------------------------ eepa 9 it: Distance to nearest well_/Dp_----------._Distancem foundation-----d-----------Distance to nearest lot line_-------- Number of pits-_.._�---------- ---Lining material____/ � - _-..-Size: Diameter-------,33---- _--Depth_......, _.._�----- .-.- Cesspool: Distance from nearest well:-------------Distance from foundation-----------------...Lining material-----------------.-------------------- a � ❑`` Size: Diameter_.--- - -------------�'-; Depth------- ------ ------------------------ --------_-Li quid Capacity---------------------------9ls. � Privy: Distance from nearest well-------- ------ -----------------------------Distance from nearest-building------__-.--__________.__-___-_-_-----. I �] Distance to nearest lot lire--------------------------------------------- -- "_> y � Remodeling and/or repairing (describe): ---------------------------------- -------------------------------- ------------------'------•-------------------------------------------------------- 4 4 - --------------------------------------------------------------------- ----- --------------------- ---------------------- ---------------------- ------------------------- --•-•---------------------------•-------- - -- --------------•---------- --------------------------- ------------------•--------•---------- ----------------- ---------- ------ --- t --------------------------------------------------------------------------- ---------- ---------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 1 -hereby certify that I have prepared this application ant! that the work will be done in accordance with San Joaquin County ordinances, Sfate laws, and rules` od regulations of t Sa Joaqu' Local Health District, (Signed) = ------------- ---- -- --------- (Owner and/or Contractor) 1 By:---i----------_--•------------"'--------------- '------------------------ ------- ---------------------------------------------(Title)-------------------------------- ------ -- - - ----------- -- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). c ! FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_____..........: - --------------------------------- DATE-----------*fes/Q- `1---------------- - . .....�._ -- - REVIEWEDBY- -------------- -- ----------------- --- -------------- ------- --------------------------------------------------- DATE------------------------------------------------------- BUILDINGPERMIT ISSUED------------------- ---------------- ----------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations---- ---- - ------ ---------- ----------- --------------------------------------------------------------------------------------------------------------------- t -------------------•---------------------------------------- ------------------------------------------------------------------------ ---------------------------------------•- •----------------------------------- --------- ----------------------------------- ------- -------------------------------------------- ---------I------------------------------ -- - ------ FINAL INSPECTION BY:.,,K .. ---------------------- Date----..- '-�7-----0------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hozellon Ave. 300 We51 Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California