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rUK UrrIC E USE: A._- LICATION FOR SANITATION PER Permit No. ,.2- --------------------- --------------------- ----------------- ------ (Complete in Duplicate) —f --------------------------------- 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. JOS ADDRESS AN OC � t� -------------------------------------------------------------------------- ----- Owner's Name `e- ----- 2r1 ----------- Phone:.....--_------------------------- Address __............... .. ----------------------- - -------- ------ ------- r -------- ---- ------- --------------------------- .----------------------.......... Contractor's Name_______________ r Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Q=* [R Motel ❑ Other ❑ Number of living units: __./. Number of bedrooms .---/ Number of baths ----/ Lot size --- f __ ______________________________ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table _ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[Hardpan ❑ Previous Application Made: .(lf yes°.date_...................) No Eg,� 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.) t Septic T nk: Distance from nearest well__/4_%°__Distance from foundation_., ��_E____.Materiai__ �' ''________________ ________________ ,. No. of compartments------------�---------Size_ . - - ---.---Liquid depth----�----------------Capacity----ge!�?;�.-- e Disposal Field: Distance from nearest well./14`!'20----Distance from foundation.-R_ .........Distance to nearest lot line-2t,5----- s-=-- Number of lines____ __ _ Length of each line----- �-----_--____.-.Width of trenc - _ _�$ "_.___________ __ zGe___Depth of filter ` __________________- material___f _' ._Total len th__ .__.__�G ___Type of filter, material_ _- _ Seepage Pit: Distance to nearest weft }__ __Distance f om foundation_ f __-___. 'stance to nearest lot liner_.___-.._ [� Number of pits-___./__._--__-Lining material_je&'-----.-Size: Diameter.__ 3-F-- --______________ Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material____...__-__---_____________________ Size: Diameter--------------------------------------De th---------------------------- -----------------_Liquid Capacity is "] r Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-------------------------------------- 0 Distance to nearest lot line-------------------------- --------------- ---- --------------------------------------------- ---------------- ----------------------- Remodeling and/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------- ----------------- -------------- f 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, &Sflaws, and rules and gulations of the n Joaquin Local Health District. •caner and/or Contractor (Signed) / I By:----------------------- - ------------------- - - - - ---------------(Title)-- --- -----==��--------- --- ------ -- (Plot plan, showing size of lot, location of system in relation to w s, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------- ------------------------------------------- DATE------G 5-�.F�.----L----�7_------------- REVIEWED BY------------------------- ---------------------------------------------------- ---------- DATE-- --------------------- ------------------------------------ ----------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE--------------------------= Alterations and/or recommendations:_.____ ______ -----=------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------- ----------------------------------- ------------------------------------------ ----------------------------------------------------------------- ----- -------------------- FINAL INSPECTION BY:------ / .<.:`.__.C- -------------------- Date------ -`---.-moi'--`-�--------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT s 1601 E.Ha:ellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stocklon,California Lodi,California Manteca,California Tracy,California F.P.CC.