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FOR OFFICE USE: t -------------------------- 3 ------- APPLICATION FOR .SANITATION PERMIT Permit No. _/9 --:-------- �---= ------------------------------- (Complete in Duplicate) --b ' . This Permit Expires i 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 .1 1 J08 ADDRESS AN CATION , 0 ------------------------------------------------------------------------------------------------- Owner's Name- -- -- --------- -------------------------------------------------------------- Phone------------------------- -------- Address- ----- e -- . �•. -------------------------------- Ph e Contractor's Name --------------- - ---------- ----- --- ....--------•- �r 't Installation will serve: Residence �partment House El Commercial ❑ Trailer Court 0 Motel ❑ Other ❑ Number of living units: --f-- Number of bedrooms __ -_ Number of baths _/___ Lot size --------------------------______ Water Supply: Public systEm Community system ❑ Private ❑ Depth to Water Table tt- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Gay Loam ❑ Clay ❑ Adobe [ ardpan ❑ Previous Application Made: (If yes,dute-------------------- No ew Construction: Yes ❑ No FHA/VA: Yes ❑ No ®-- TYPE OF INSTALLATION}AND SPECIFICATIONS: (No septic tank or cesspool permitted if.public sewer 1' available within 200 feet.} Septic Tank:, Distance from nearest well_________________Distance from foundation--------------------Material__-_____---__--_--_--__-_-___-______-_________- D A *F No.Distof from rne'Ints----- --------------------Size------------------------•---=---Liquid dept`--------,11-----------------Capacity----------------------- ;0 well _.-.'-.-.Distance from foundation__.Z,07-------Distance to nearest lot line_ __��____. f, Number of`ines_---___ _-_-�_.__ ___- Length of each line__n��__�----------_-Width of trench--A "'_____________ ______ T e of•filter material Total length -----------! Yp 10 Depth of filter material---`P ---_ ' �� : .. 5� Distance #o nearest well____ _ -----Distance from fo dation__-_.IP---___ Distance to nearest lot line._-________-___-_ Number of. its----Y p�# -------------Lining material-- � �.5ize: Diameter---i - Deptllm"°c' �/ '_. F ❑ Size; Diamete-'�-a- ------ -------------------!---Deofh------ -------- ------------------------------------Liquid Capacity----------------------------gals. i ./Cesspool.` Distance.fron•i nearest well_____________;___Distance from foundation_------------------.Linin material_-_-____------_--__--_________-_. �` i Privy: Dis#ante from: Barest well__._________--_----____._____________________Distance from nearesf building---_----__-__-__-__________---_-__-__-_ ❑ Distance to nearest lot line - ----------- F A # Remodeling and/or repairing [describes:---___-- - -- --- G _-- ----•-----e_________#•------------------- --•---------------------------------- ------------------------------------------------------t------- ----------------------- -'------------------ ------------- f t ;� r = ---•-------------------- ---------------------------------------- __________ ;.► i I hereby certify that 1^11have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, andyrles and r gulations of the San Joaquin Local Health District. (Signed)------------------ -------------- = ------ -- ---- ---�L-� ------------------- ------------------- or Contractor) By: --------------------------- --= -- -------------- ----------------------- ---------- - ----------(Tale}-_ _a ...------------.--....... - ` (Plot plan, showing size of.lat�location�of system in relati o wells, buildings, etc., can be placed on reverse side}. a x � i FOR DEPARTMENT USE ONLY KAPPLICATION'ACCEPTED BY-------- - ----------------------------------- DATE----- ----- REVIEWED --REVIEWED BY- a--------------- 1$---------- ------- ------ DATE BUILDING PERMIT ISSUED- 1------------- - - - ------ ----- --- - --------- DA•TE--------------------- ---------------- ---------------------- -------------------------- Alterations and/or recommendations-----1-� / - -- ---------------------------------------------------------- ---------------------------- ----------- ------------------------v t- ------------------------- - --------------------------------------------------------------------------------------------------------------------1-• ------------------ # ' ------------------ ----------- -------------------------------- ---------------------------------------------•----- ------------------------------ ------------ ----- ----------------- ------------------- ----------------- --- ----------- ------------------------------------------------------------------------------------------- ------ --f---------------------------------------- F f FINAL INSPECTION BY:.---- ---------------------- Date------ - -----------------� - - 1 - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street I Stockton,California Lodi,California Manteca,California Tracy,California .r