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FOR OFFICE USE: 3-D --------------------------------- _------------- APPLICATION FOR SANITATION PERMIT Permit Na .�.� .... (Complete in Duplicate) _------------- This Permit Ex ires 1 Year From Date Issued ©ate 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 compliancewith County Ordinance No. 549. JOB ADDRESS AND LOCATION-----/- --2` _---�L<__- '�Q�' --- Owner's Name----- ----------- --- ------------ ------------ Phone-------------------------------- Address---------- +� f-�!_CJ' L -------------------------------------------------------------------------------•-----•--------------------------------- Contractor's Name------ --- `�` 7--S ------------------------------------ ---------------------------- ---------------- Phone---------------------------------- Installation will serve: Residence ®Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --1---- Number of bedrooms -f- Number of baths ---Z- Lot size ------k ) r 5-0 ----- ----------------------------------------- Water Supply: Public system [Community system ❑ Private ❑ Depth to Wafer Table -4.0.- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sand Loam E] Ciay Loam ❑ Clay Adobe �ardpan El 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.) an ; Distance from nearest well-----------------Distance from foundation--------------------Material_---.------_--___--_-______----_---------.---. No. of compartments-------------- -----------Size---------- -----Liquid depth---------------- -------- Capacity------ --- ----------- Sept9�� Disposal Fi Distance from nearest well..--. -------Distance from foundation--/9.............Distance to nearest lot line-1.5---`----- Number of lines-------------------------- -------Length of each line---%4--------------------Width of trench--.Z�-�'------------------ Type of filter material �. G. ------Depth of filter material----f r.��------.-Total length---.-----_4-0-1---------------_-- "f' e t'it: Distance to nearest well-_- ------------Distance from foundation--LQ--------_-Distance to nearest lot line--<:5 l�, .------ I / —[ F / ©� umber of pits--------- ------- ---Lining material--�- o4'S~-------Size: Diameter-��-�-lea_Deptn_____�.Z--------------------- Cesspool: Distance from nearest well ----------------Distance from foundation....-__-.------- -.Lining material-.------------_-- ----------------- ❑ Size: Diameter---- ---- --------- ------------- -Depth------A--------- -------- --- ------- -------------Liquid Capacity----------------------------gals. Privy:- Distance from nearest well---------------------------------------------- --Distance from nearest building ---...---.--_._-----_____-__--___-____. ❑ Distance to nearest lot line - --- ---- ---------------------- ---------- - -------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe)-------- ---------- --- ------------------------•-------•-•---------------------------------•--------------------------------------- ------ -----------------------•---------------------------•---•---------------- -----------------------------------•---•------------------------------------------ --------- ----------------------------------------------------- - --- -------------- -- -------------------------------- -------------- ---------•------------------------------------------------------------------------------------------------------------------------------ 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, an r and r ulglons of Pe San Joaquin Local Health District. (Signed)---------------- ---- ---- --- - - --- ------------ ---------------...----------------------------------------------------(Owner and/or Contractor) Sy:--------------------------------- --------------------------(Title)-------------------- -------------- -- - ---------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 8Y --U�- ------------ ------------------ DATE v� 7 ��- -------- REVIEWEDBY--------------------------------------------- ------------------------------------------------------------------------------- DATE-------------------- - - ------------------------------------ BUILDING PERMIT ISSUED----------------------------- ------------------------------------------------------------------------ DATE------------------------------------- Alterations and/or recommendations:------------------------- --------------------- ------------------------------------------------------------------- ---------------•---- ---------------------- --------------------- -------------------------------.- -------------------------------------------------------- ---------•---•----------------------•---------- ------------------------------------- ---------------- ------------------------------------------------------- ----------- ---------------------------------------------- - -------------------- --------------------------------------------------------------- --------- -- - -- ---- -- ------ - --- -------- ---- -------------------------- -- ------ --- - ----- ----- --------------------------------- ------- --------------------- FINAL ----------------------------------- FINAL INSPECTION BY:..... . .i / `:. Date-----------`�-------�--- -�------� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P,c o. !