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FOR OFFICE USE: F ----------------------- ------------- ------------------ APPLICATION FOR 'SANITATION PERMIT Permit ------------------------------ --------------- ------ (Complete in Duplicated c �� :"_ 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 a work herein described. This application is made in compliance with County Ordinance N. 549. JOB ADDRESS A OC N `� _--- -- --- --- ------ -_ Owner's Name____i! - -------- 1,71- ------------- ---- Phone------------------ =_------------- Address-•------------ --- ---- -- -- -------------- --- ---------- ----------• -- ------ --- -------------•---------------------------- ---------------- -------------------------------------=-------.. Contractor's Name Phone k07- Installation will serve: Residence I& 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 % Depth to Water Table&.Q- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeA 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: No. of compartments tst well---------------- Distance from foundation--- ______________-Material-___....____._._____...._____________,_____-_-_. ❑&L444)G P Size---------------------------- ---Liquid depth-------------------------.Capacity----------------------- Disposal Field: Distance from nearest well--------------_,,Distance from foundation-----------------_Distance to nearest lot line----------------- E]g3CkS4A)6 ________.._____❑g3CkS4A)6 Number of lines----- --------------- -----------'Length of each line------------------------------Width of trench----------------------------------- Type of filter material.___.________.._--_____ Depth of filter material----------------- length__.____..___________-___________________ f Seepage Pit: Distance to nearest.well.,�. r_._._.___Distanc"Om undation___W_.______- Distance to nearest lot line-+�_______-- Number of pits Cl). Lining material_ Size: Diameter -.......---Dept'rl-- -.5 -1 E 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----------------- -------------------- ------------------------------------------------------------------------------------------------ Remodelingand/or repairing (describe):---:-------- --------------------------------------------------------1----------------------------------------------------------------------:---------- -------------------------- ---------- ----- -- Ihereby ertif that I 4rulesd -----------------------------------------•--------------------------------- ------------------ ---- ------ ---------------------------- ------- y y havethis application and that the work will be done in accordance with San Joaquin County ordinances, State laws, andia�ons of a San Joaquin Local Health District.---- -- --- - -------- ---------- ----------------- -- caner and/or Contractor(Signed)--------------------------------- � --------------- By:----------------------------- ----- --------(Title) `. --- (Plot plan, showing size ofystem in relation to ells, buildings, etc., can be plac on reverse side). 1 FOR,.DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------- z � ---- -------------------------------------- DATE REVIEWEDBY----------------------------------- ---- ---------------- DATE BUILDINGPERMIT ISSUED---------------------------------- ------------------------------------------------------------------ DATE------------------------------------------------------------- Alterationsand/or recommendations:-------------------------------- -----------------------•------------•-----------•-------------------------------------------------------------------------- ---------------------------------------------------------I---------------------------------------------•----------------------------------------------------------------------------------- -------------•----------------•--- --------------------------------- C-3 FINAL INSPECTION BY:_ Date ~'1 f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.EIG-