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I-OR UFFICE USE: --------------------- ----------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .Q�LI —3 ---- ------------------------------------- ---- -- (Complete in Duplicate) e. --------------------- -- --- This Permit Expires 1 Year From Date Issued Date Issued __�� Application is hereby made to the San Joaquin Local Heal}h District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESSSLOCATiON' �J �� - 4 -- -- . ---th-L- '`----�--- ?zk6.t�!,!V�__ - Owner's Name =f ----------------- --------------------- ------ ---------- Phone------------------------------------ Address-------------- -- 1" Contractor's Name--- ---- rz. --- - --------------------------------------------- --- --- ------ Phone----------------------------------- Installation will serve: Residence [!(Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other ❑ Number of living units. Number of bedrooms ..3__._ Number of baths __/---_ Lot size _________________ Water Supply: Public system ❑ Community system ❑ Private V� Depth to Water Table ________ £t. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [] Clay ❑ Adobe ❑ Hardpan Previous Application Made: (if yes,date--------------- ---) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material-----------_------_--------------------.......... ❑ No. of compartments------------- ------------Size--------------------------------Liquid depth--------- --------------Capacity------------------ Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line_______-.----____ ❑ Number of lines------------------------------ ----Length of each line---------------------------._.Width of trench-------------------_ Type of filter material-------------------------Depth of filter material----------------------- length_____________________________-___.__-.__ Seepa Pit: Distance to nearest well-----_-/1p..---__Distance from foundation_-_.-?-4? Distance to nearest lot line---•��_�______ Number of pits------_-/------------Lining material___-----5--]Z......size. Diameter--------- DeptFs___ _r........................ Cesspool: Distance from nearest well-----------------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 Remodeling and/or repairing (describe):----- ----------------------•-•----------------------------------------- ----------------------------------------------------- -- -------------------------------------------------------------------------------------------- -------------------------•--------------------------------------------------------------------------- --- - - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) -------- 9 �-------------• - -------------------------�- - ----- - - - - qer and/or Contractor) -- . - . _ BY= (Title) (Plot plan, showing size of lot, location of system in r lation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- - --------- -- -- - - - --- --------- --- -- ---------------------------------------- DATE----`5 + TY! REVIEWEDBY- ------------------- ----- --- -- --------------------- --------------------------------------__ DATE----------------------------------- BUILDING PERMIT ISSUED---------------------------------- --.-.- HATE-------------------------- ----- Alterations and/or recommendations----------------------------------- --------- - -------•-•---------------------------------------------------•----------------------------------------------- ----------------- ------------------------------- ------------------------------------------------------------------------------------------ .---------- ---------------- ---------------------- --------------------------------------------------------- ------------------------------------•--------------------------------------------------------•----------------------------------------------- ----------- ------------------------ •--------- ------------------------------------------------------------ - ------------------------------------------------- -- ---- -------------------------- FINAL INSPECTION BY: -------------------- Date--` 2 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haielton Ave. 300 West Oak Street 124 Sycamore Street 205 west 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.r,q.