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FOR F CE USE: r r (- ______________i l -_.___�_ _.6,--.--__ -�.- APPLICATION FOR SANITATION PERMIT Permit No. ------------------------------------- ----------------- (Cornplefe in Duplicate) --------------- This Permit Expires 1 Year From Date Issued 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. An 4 JOB ADDRESS AND LOCATION------(/1 �---�_C�----------At---- - ----•-•-• --•--/ - --------- ---------- -----------------------------------...----------- Owner's Name--------- -- ------------------------------------------ Phone..--------------------- --- Address ------- - .-7VJ_!7-- - - - -------------I--------------------------------------------------------`-.......... Contractor's Name -- ----- -------•- ----------------- ----- ------------------- - ----- -- - ---- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living -/_units: �-- Number of bedrooms c2_ Number of baths _/- Lot size ---�-�3 Water Supply: Public system 59�community system ❑ Private ❑ Depth to Water Table*5_4 ff. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe M' Hardpan ❑ Previous Application Made: (If yes,date-----------:_-__1 N 01 New Construction: Yes ❑ No X FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Tank: Distance from nearest well-----------------Distance from foundation_----------------Material------------------------------------- No. of compartments----- -------------------Size-----------------------•-------Liquid depth---------- --- ---- Capacity Disposa Field: Distance from nearest well - --- .__Distance from foundation,11-4-- j-----Distance to nearest lot line------ -.-._. Number of Tines------------------- Length of each line----------- ------ -Width of trench.----_ir _ ------__--___-_____ Type of filter material./ _ Depth of filter material__ Total length f g ---.•------ Seepage Pit: Distance to nearest we1l_7?td1A'__Disfa ce om foundation---14-__--_-. istan� to nearest lot line--- -------- Number of pits--------/------- -__Lining material_ -.1D_../_._.__.Size: Diameter_--r �--.---.-___ Dept h------r7-��------------ Cesspool: Distance from nearest wo}i-----------------Distance from foundation- ------_-----------Lining material------------------------------------- El Size: Diameter-------------------------- ------ ----Depth--------------- ------------------------------------Liquid Capacity-. .-------------------_--gals. (h Privy: Distance from nearest well--------------------------------------------- -Distance from nearest building---------- ____----_----___-----..------_ ❑ Distance to nearest lot line-------- Remodelingand/or repairing (describe):------ -- ----------------------------.-.---------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------- ------------------------------------- -------- ----------------------------------------------------- ----------------------------------------------------------------------------------------------------------••------------------------------------------------•---------------- ------------------------------------------ --- 4� I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St laws, and rules and re ations of the San Joaquin Local Health District. (Signed) -- ---------- ----------------- -- - Owner and/or Contractor} By:-- - --•- --- - - -- f - ----- ---- ---------------------------------- -------------------------- Title--. ---- --------- (Plot plan, showing size of lot, Iota of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY j APPLICATION ACCEPTED BY---- --------- r--------------------------------------- DATE-----lF `T i 7 ---- REVIEWED BY------ -------------------------------------- ----- ------- ----------- -------------------------- ------------------------- DATE----------------------- .. UILDIN PERMIT ISSUEQ ---- ----- ------------ ------------- ---- ---------------- DATE-------------------------------- Alteratins and/ r�ecommidations: -'----------- - - .. . �---------� -------- --r----- ----------- ------ --• ---- - -- ------------------------------ ----------------ri.------ •' --------- -- ----------------------- � ---- ------ FINAL INSPECTION BY:-. Date 1 -------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 134 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California