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FOR OFFICE USE: ,. -------------- ---:--------------------------------- - G --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No -- -- (Complete in Duplicate) ............. This Permit Ex ires 1 Year From Date Issued Date Issued _.___ 2rg - ; 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 Ordinance No.,549. JOB ADDRESS AND O ATION J� F._�-.__ _ 1 c -._ �_s'' Owner' a /F �. -�-- Phone_ ---- --- /j_ /y/L110- --- Contractor's Name t �` •---- ---•--- Phone-- ---��- � � A artme?it ouse Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Installation will serve: Residence �p ❑ r Number of living units: -----1_ Number of bedrooms _C_ff.- Number of baths Lot size __�_________________________ ___________•----------- Water Supply: Public system ❑ Community system ❑ Private U?"D'epth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam Clay Loam [I Clay ❑ Adobe C] Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ No HA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic t or cesspool-permitted if public sewer is.available within 200 feet.) i an Distance from nearest well-__-------------Distance from foundation_-.--_.-__---- Material____- ________._- __.___._. No. of compartments------------ -------------Size.-------------------------- ---Liquid depth------------ - - ------. Capacity-----------.�---_• t �� --- satice t lot fiN: Distance from nes t wel1:-�._0_o-.�Distgance from fou�s " 'dtlgtr�nche5 1 -- ---- ------- Number of lines- Length of each li -_A r Type of filter material- epth of filter materiaL___�-__ Tota kength____1QQ__-._.....____..._... .-.--_Distance from foundation--------------------Distance to nearest lot line--.------__.--.-_ Seepage Pit: Distance to nearest well---------------------- � ❑ Number of pits----------------------Lining material-----.---.---_I_`_._.Size: Diameter-----------------------Depth__ --------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation.----.--------------Lining material--------..-__-_-----____''__----.-_-_- Size: Diameter-------------------------------- - -----------------Liquid Capacity- ----------------------•-•-gals.. ❑ Depth---- ---------- ----- - I � .0 Privy: Distance from nearest well-------------_----------------------------------Distance from nearest building---------------___________.___._- ----. ❑ Distance to nearest lot line--------------------- ------------------------------------------------------------------------------------- --------- 1 ' Remodeling and/or repairing (describe):------------ ------ --------------_ -------------------- `------------------------------------------ -----_---------- ------------------ -- ----- ---------------------- --------- �x ---------------------------------------------------------•--- --- - ------------------------------------------------------------------------------- ------------------------------------------------ --- ------- ----------------------------- I hereby certify th . I have pared this application and that the work will a done in ordance with San Joaquin County ordinances, a s, a and regal I sof the Waaquin Local eal#h 'strict (Signe . . r� P --------{� Contractor). .. (Plot plan, showing size of lot, location of system in relation wells, buildings, c., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- -O r i - --------------- -------------------- ------------------ DATE-----------------1.,7-'- ��---------- REVIEWEDBY-------------------------------------------- - ------------------- ---------------'.------ ---------------------------------- DATE------ --•---------•---------------------------------------- BUILDINGPERMIT ISSUED----------------------------- -----I - - ------------------- - ----._ DATE----------------------------------------------------------------- Alterations and/or recommendations:--------------.------------------------------- '---------------•-------•------------------- ------------------------------------------------------------------- 4 -------------------------- --------------"----"-----------•--...-.-_--------..._---------.__ A /," a---n FINAL INSPECT-I.D�. . .. . - A' ----- Date-------------/----~-- ---� -------------------------- 1% SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ha:ellen Ave, 300 West Oak Street 124 Sycamore streetf 205 West 9Th Street stockton,California Lodi, California Manteca,California Tracy,California 1 'F �3