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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 I Health District for a permit to construct and install the work herein described. Application is hereby made to tits San Joaquin Loca This application is made in compliance.with-County Ordinance No. 549. �'f3 JOB ADDRESS AND LOCATION--A 1-/-.,.,--- �,/ -------------------- -------------- Phone-------------------------------- Owner's Name _r�'la.r/u � dr-L� -----------------•----------- Address-----••-- f -----� ------- ----------- -- •---- --------------------•---•--------------- -- Con#ractor's Name.../ ". � z` -- --------- �'/►af_. r�str �r------------- Phone_.. -- Installation will serve: ResidenceN Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ ----- Number of bedrooms _ -.- Number of baths , Lot size - ---- Water Supply: Public system ❑ Community system ❑ Private J] Depth to Water Table _f_ "ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 9d Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,dote.-.-----------------I 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...S-qi____Distance from foundation_-)�!____--_ _ _ ._.Material--___----- ..._______________"____ --_. - --- No. of compartments----�------------ - �- ----Size--A_tj� --: Liquid depth------�-------------- Capacityl.Z- - - �1 - / Disposal Field: Distance from neare f wed-r-6-------Distance from foundati�opn. t'-�--._ "Distance to nearest lot I�ne___sr__-_______ .S o ® Number of lines-- -------!74-- -- --------- Length of each line_----G--G_--_--__-----------Width of trench._s��---.-------------------Type of filter material _ Depth of filter material-___.- _-____.Total length__ -4�_ ___________________________-_.Distance to nearest lot line..__--______..._Seepage Pit: Distance to nearest w __ ______________Distance from founda#ion_____________ sl ❑ Number of pits----------------------Lining material-------------------.--.Size: Diameter------------------ --Depth----------.--------- ------------- Cesspool: Distance from nearest well-----------------Distance from foundation....------------- - Lining material------------------------------------ El ---"- --❑ Size: Diameter-, ------------ ---------- - ---.De th------------------------------ ---------------------Lquid Capacity----------------------------gal __________._..._____________Distance from nearest building_.-----__._----_____-_______-"_..._---.- Privy: Distance from nearest well____________________ ❑ Distance to nearest lot line-___--__-----_._-__ Remodeling and/or repairing {describe):---------------------------.---------- ------------------------------------------------------------------------------------------------------------- ---- ----------------------------- ----------------------------------------------------------------------------------------------- -------------------------------------------------------------- -------------------- ------------------------------------------------------------;-------- ------------------------------------------------------------------------------------------ ' ------------------------------------------------------------------------------------------------------ rr -------------------- ------------------------------------ -- - - -- l� I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules anttd regulations of the San Joaquin Local Health District. a O i -`- -- ---- � (Owner and/or Contractor) (Signed) ---------------------------- ------------------------------------�- -------------------------------------------------------------(TitIe)........................................... .- t (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 fi I / " 6,{"-------------------------------i r APPLICATION ACCEPTED BY - _ _______________"---- DATE--- j REVIEWED BY--- ----------------------- ------------ -------- --------- --------- -------------------------------------- -- DATE-------------- --------•------------------------------------ ----- , BUILDINGPERMIT ISSUED------------- ------------ ---------------------------------------------------------- DATE Alterations and/or recommendations:--------------------------- ------ -------------•----------------- - ----------------------------------------------------------- --------------------- -------------------------------------•----- FINAL INSPECTION BY:.- _ .- .. Date SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave, 300 west Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California F.P"C o.