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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. .................... ------------------------------------------------------ {Complete in Duplicate) -------------- ---------------------- --------------- - Date issued --------------------------------------------------------- This Permit Expires 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. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION---------------- - -�� . '-------- A.Z�------•---------------------- ---- -_------------------- .......... A Owner's Name---------------------- -•--- ----------••--------------•----------------------------------- Phone__..--------------•--_-------•-- Address--------------- -----_--_--------------llD- 14111 5��/_�t�.Cz --- Phone.......Name------••-•--------------------- -----• --• -- -- ---------------- -----fi------------------------•-------•----••------•----• - ----------------_------- , Installation will serve: Residence,� Apart ent House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ .� / i Number of living units: ----/-- Number of bedrooms - . Number of baths __.f__ Lot size ......550._____K__l-o7Q______._____.______-_•__. Water Supply: Public system J�9- Community system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adoben Hardpan ❑ Previous Application Made: (If yes,date---------------------) No In New Construction: Yes tg- 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-__60 ______Material--- No. of compartments---------- -----------Size----- Liquid depth_-------y:�-----------Capacity._.__- C' I Disposal Field: Distance from nearest well-----/t�N Distance from foundation_--__--�--------Distance to nearest lot line----- 14 Number of lines-----------------_3-------------Length of each line_ 1N,dth of trench.______ f �r ;------------ Type of filter material_..,4a_t�-------Depth of filter material____, 9______-Total length---------------l_k-_�•_________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line_______________._ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation____----------------Lining material_---------.-________.______-_______-. ❑ Size: Diameter--------------------------------------Depth------------------------------ --------------------Liquid Capacity----------------------------9 Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------- 11 ____._________-;__.-.....___-_______.._.❑ Distance to nearest lot line--------------------------------------------------------------------•----------------------------•---•---•-------------.... ----------- Remodeling --------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 f the San Joaquin Local Health District. �1 --___.__._Owner and/or Contractor (Signed) ------------ ( ) By:------------------------------------- ----------------------------------------------------------------------------------(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------ Ar --------------------- REVIEWED BY--------------------------------------- • = DATE BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------------------- DATE--------•--•--•--•------------------------------------------- Alterationsand/or recommendations:------------------------------------------------------- = = =-•---------------- ----------------_----•-----•---------------------------------- -------------•-- -----•--••-•-------------•-••-------------------------------- *k.i;-------6;L-- ------ -- ------- --------------------------------------------- ----------- ------- ----------------- ------ ----------- -------- � Vis: --- --- ::: ---=-- ---------------- ----: ------------------------- FINAL INSPECTION BY . ------ ---•--------- -------- --------- Date G �� SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California EB-9 REV16E0 8.09 F.P•C0.2M 6.60