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FOR OFFICE'USE:. APPLICATION FOR SANITATION PERMIT Permit Mo. .. .....:............ ----- --- ----------------------------------------- -- (Complete in Duplicate) Date Isrd_-`tea _----------------_..:------------------------ ... This Permit Expires I Year From Date Issued ApplicationI,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----------------- ✓ - r� ----------------------- 0 12 er's Name Q /- �OwnPhone-------- ---------------•------------ � � �� Address._ ... -- -- -------- � .---•----------------------------------------------- j Phone.Contractor': Installation will serve: Residence 21- Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___,('_ Number of bedrooms _Z--- Number of baths -./.._ Lot size ----- , _X__ev---------------------------- IJ 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: (If yes,date---------- --------) No 9--"New Construction: Yes ❑ No ED---THA/VA: Yes ❑ No ❑I TYPE OF INSTALLATION AND SPECIFICATIONS: (No it septic tank or cesspool permitted if public sewer is available within 200 feet. , Septic Tank: Distance from nearest wek-----------------Distance from foundation-------------------- _ _ __ _ -Material------..-------- ----.------_--- -.-- _. _. ❑ �I No. of compairtments--------------------------Size--------------------------------Liquid depth----------------- ------ -Capacity-------------- ------- Disposal Field: Distance from nearest well----.------------Distance from foundation--------------------Distance to nearest lot line----------------- EJ Number of lines------------- ------- -----_-__--Length of each line------------------------------Width of trench---.---------------- -------------- r, -- .Ii Type of filter'material-------------------------Depth of filter material-----------------------Total length----------------------------------------- S l - � Seepage it: Distance to nearest well____.- ------Distance from foundation---,/5r___---_-.Distance to nearest lot 11Number of pits--- -----------Lining material- 1L1,�__..-Size: Diameter._._.__...___Depth__------------------ :: Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material----------_------------..___________ LA Fj Size: Diameter--------------------------------------De th--------------------- ------- ------ --------------Liquid Capacity all. Privy: Distance from nearest well --------------------_------------.--------.----Dis+ante from nearest building------------------------------------------ ❑ Distance to nearest to+,line ------------------------------------------- ------------------------ ----- Remodeling1and/or repairing (describe):___.-. . _Ial ----------- Z,_5_277 e�------�E/ _.�_ ------__-___- ------------------- ------------------------------------=----•-----------------------------------------------•--------------------------------------------------------------------------------------- ------------------- ---------- ----------------------------------------------------------------------------------- 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 of the San Joaquin Local Health District. Tx-1 1 fly, _ - i�l--��----------------------------- ------------------------- n and or Contractor (Signed) � r By:"----------- = ----------------------------------------------------(Title)--- -------- ----------- (Piot plan, showing size of lot, location o ystem in relation to wells, buildings, etc., can be placed on reverse side). t� ii FOR D ARTMENT USE ONLY APPLICATION ACCEPTED BY-- F C - ----------------------------- DATE-----/� ----------- R EV I EW ED i-BY------------------------------- DATE -------------------------------- BUILDING PERMIT ISSUED------- - PATE------------------------------- ------------------- ------ Alterations-and/or recommendations:--.-_:•�----- - ----- ----- �f._...._.____ ._._.___ ___��:----- ------ - ' i -------------- ----- i ( c— i.i -------------------------- I I FINAL INSPECTION BY:.... _ -.- - Date----- r� 5AN JOAQUIN LOCAL HEALTH DISTRICT 1501 E.Haxellon Ave, 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi, California Manteca,California ;Tracy,California ,