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t-UK Ul-H : USE: � - -------------------- ------ ------------------------ ---------------------------------- -------------- APPLICATION FOR SANITATION PERMIT Permit No. .-. - ---------------------- ----------------------- (Complete in Duplicate) This Permit Ex fires 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. JOB ADDRESS AND LOLCATION_ ----- - � � Owner's Name ---------------------- ------------ - -- --------.-- r. -- ----. Phone---5o e7 Address..... ".`l "� ------------------------•----------- -------------------------------------------------------------- Confractor's. Name----------- 5 ------------------------- -------------------------------------- --.... Phone. Installation will serve: Residence [j]Apartment House 0 Commercial ❑ Trailer Court ❑ Motel ❑ Other i g - Number of living units: 'Number of bedrooms --� Number of baths -_ -- Lot size _- --__-y --------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet. Sand ❑ Gravel E] Sandy Loam E] Clay Loam E] Clay [_1Adobe E4--Hardpan ❑ Previous Application Made: {If yes,ilate---_._-ib-_ _ .- } No [yrTVew Construction: Yes ❑ No [P/FHA/VA.. Yes ❑ No [� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitfed if,public sewer is available within 200 feet.} Septic Tank: Distance from nearest well-----_-___----_Distance from foundation_.--___--- _ .-- 4 . Material------------------------------------------------ No. of compartments-- ------------Size------ ------Liquid depth-------------------------Capacity Disposal Field: Distance from nearest well__ .`-r'-_ _:'Distance from foundation----/l�------- Distance to nearest lot line--_..& �.. ` , Number of lines-------------- -�.- ___ _-_- Length of each line----------./04o!_'--__ .1�1/idth of trench-.-.-._ Y Type of filter material __Z ---------- YP T -Depth of filter material_---- ylf-------Total length-__---____jd?n- ------------------ W Distance to near'st well_.----______----_-__Distanc:e from foundation----_L�"'.-_--.D stance to nearest lot fine_-.-. �__-_ Dumber of pits--i---- ___________Lining material__ ►' / Size: Dianne"' Distance from nearest well--'-------------- from foundation----- ___---._Lining material-_--__--____ + ❑ Size: Diameter-- -- ---- ----' ------- ----Depth---- Liquid Capacity ----------gals. ---------- - rivy: Distance from nearest well--- _.____ --_-_Distance from nearest building—g---------------------------------------- ❑ Distance to nearest lot line___--_____-•____.A.-_ - ---._- f0 ---- ----------- ------------------ ------------------------------------------------------------ Remodeling and/or repairing (describe)------------------ ' --------------------- ----------- -----•----- `. - ! ------------------------------------------------ ---------------------------- ----- ii •---------------------------------------------------------------- ---------- -------------- -------- ----------------------•------------------------------------------------------------------------ __ - ----------- I hereby certify that I have repared this application and that the work will be done in accordance with San Joaquin County ordinances, Sta laws, and ru an �gulaffionss of the San Joaquin Local Health District. (Signed)_ -- __-- ----------------i ----------(Owner and/or Contractor) Plot plan, showingsize of lot, locatio# of system in relation -------(Title}--------- ------------------------ ----- ----- to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY - APPLICATION ACCEPTED BY----------- --------- DATE $1�G� ------------- REVIEWED BY ------------------ ------#- ----- •- DATE= BUILDING PERMIT ISSUED ----------------------------------------------------------------- ---- DATE Alterations and/or recommendations:.!_--..--._.-�,�/ �._G'-��1 �.�---�r�?f�-------------------f----_ ---.- -------------------------------------------- - - -------------------- •----------------- ---------- - --------------------------------------------------------------- w I ------- d. � FINAL INSPECTION BY:------ -----� C/f - - Date SAN JOAQUIN LOCAL HEALTH DISTRICTt •---°'Y r 1601 E.Hazelton Ave. 300 West oak Street 124 Sycamore Street 205 West 9Th Street Stockton,California Lodi,California _ Manteca,California Tracy,California F.F.CO.