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OFFI FO CE SE-,/� _---- APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) ___ _ 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 the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS A LOCATION " '= �`--...4�-- 1 1 ------------------ W "--� '"�!"` . .. :--..:.. =' Owner's Name...-- - 5 -- Phone Address-----....... ?t r -- ----------------` -------y-•------ - --------r------------------------------------------------------------------=-------•-• ---- ---- � Contractor's Name------{ 1 l ---- y1� ---------- Phone-/----- -`�: 7. _ ------------- Installation will serve: Residence1 L� ^ artment House ❑ Commercial ❑ Trailer Court. ❑ Motel ❑ Other ❑ Number of living units: ---(_ Number of bedrooms _ . Number of baths __V,_ Lot size ----1--�--------------------------------- Water Supply: Public system ❑ Community system ❑ Private epth to Water Table _k4p 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 2-- New Construction: Yes [M o ❑ 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: Distance from nearest well__47�__r_-_.........Distance from foundaton_ ?_4..._____-_. � ? --__-- Mate-ri-a--l-_-.-.-------C?:apaec`i{tPy-_-,.�No. of compartments---------�---_--- - Size__syr . Liquid depth----- Disposal,Field: 'Distance from nearest well__6T-------.-Distance from foundation._...........Distance to nearest lot line__________. , Number of lines_____________'1_--__._ _.________Length of each line______7�_____________-_-Width of french-------__ __`___-____-___-_--- Type of filter materiaE___ Q_�! ---------Depth of filter material--/Y................Total length_______1�'a__:________,l-______ Seepage Pit: Distance to nearest well_jAD_ __________Distance from foundation__3ZI .-_-__-_____.Distance to nearest lo# Number of pits----ty -------------Lining material_'XQ_C-_(-------Size: Diameter---- ----------Depth-------- r `-----------• ` Cesspool: Distance from nearest well-----------------Distance from foundation.--_---_____-___..Lining material------------------------ + Size: Diameter--------------------------------------De Depth •------------------------------------------•-Li Liquid Capacity .. r ❑ p q p #Y--------------------------..gal . Privy: Distance from nearest well_____________________ ___________________________Distance.from nearest building_____--___________---_---_-______--_____. >, ❑ Distance to nearest lot line------------------------------------------------------------------..........-----_-----------------------•---------------------------------- Remodelingand/or repairing (describe):-------------------- ------------------- -----------------•---•----------------------------------------------------------------•--•---------------•--- '� - ---••--•---••-----------------•----------------------------------••----------------•----------------------------------------------------------------------------------------------•--•------==----•-•------------------------- ---------------- ------------------•-•---------- --------------------••-------------------_-.----------•--------•--------------------------•-_--...---•---------------••------------------ �' 4 --------------------------------------- ---r---------•-----------------------------------------••----------••------------------•-------------------••-•---------•--•------•----------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 4 ordinances, State laws, and rules andr tions of. the San Joaquin Local Health District. i` (Signed)----------- ------ -------- ------------------(Owner and/or Contractor) by=--------------------------- • ---------------------------------------------------------------------------------------------------(Title)------------------------------- -------- --- - - --------------- (Plot plan, showing size of lot, location of system in rela+ion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- C -------------------------- DATE------ REVIEWEDBY--•-------------------• •-----------------------------------------------------------•------------------------------------• DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED-------------------------------------------------------------------------------------------------------(DATE---------------------------------------- ------------------- Alterations and/or recommendations-------------------------••------------------------------------------------------.--------------------------------------------....................... .._..... -------------------- --------------------------- - ------ ----------- - - � �y ---^------- --- ------ - - ------- - ----- ----Z__ � � ---------- FINAL INSPECTION BY:..ex` - - E Date_-------------------------- ------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California- K E9.9 REVISED 8.59 r.P.C9.2M 6.60 t