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1-UKU11-K-L USE: ---------- ---------------------------------------------- , ---- -.-.-____-----_ APPLICATION FOR SANITATION PERMIT Permit No. ------------------ -------------------------------------- (Complete in Duplicate) 1 � ............. 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 ANDOCATION-----/DD--.7'--------4� i Owner's Nam - -- ---- Phone------------------------------------ ---------------------- Address- .- f .. Contractor's Name - ---- -------------- Phone.�Gt_W_-_ _vz Installation will serve: Residence ❑ Apartment House ❑ Commercial railer. urt EJ Motel [:1 Other El Number of living units: -------- Number of bedrooms -------- Number of baths �o Water Supply: Public system W1.11community system ❑ Private ❑ Depth to Water Table4/ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [] Clay ❑ Adobe 290*'Fiardpan ❑ Previous Application Made: (If yes,date--------- ----------) No Poloo"New Construction: Yes ❑ No [L}-'HA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S ti ankh Distance from nearest well-----------------Distance from foundation-----..__-__----.-- No. of compartments------------- -------- -- Size--------------------------------Liquid depth----------------- -------Capacity----------------- yy� Disposal field: Distance from nearest well-00! __Distance from foundation-_/A!.�_.__Distance to nearest lot line__S _ --- le, Number of lines------- ---------Length of each line--------------34--------Width of french-.-._.___------ Type of filter material- i_ _O.4�CDepth of filter material___,__a_. ___-_.Total length---_------s3_d_ ---------------- _____- i Seepage it: Distance to nearest ___Distance,4m foundation---,e'�Q___.__.Dis1tan�rp to nearest lot line-_.•� ._ Number of pits.-- _�-------___-Lining material___. 0CIk__.Size: Diameter___--„3--_3_---.._-__Depth_.__pZ_ Cesspool: Distance from nearest well-----------------Distance from foundation---------------- Lining material__..----___.__-.___._____-.____.--.- O I ❑ Size: Diameter-------------------- ----------------Depth---------------------------------- -- -------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------ _-Distance from nearest buildingQ ❑ Distance to nearest lot fine ----------------------------------------------------------------- Remodeling and/or repairing (describe):�.&- . = ..mss.a------ ---- ; ---------------- -�- --------- --------------------------- ------------------------------------------ ---------------------------------------- I hereby certify that I have prepared this application and that the work will be don aquin County ordinances, ate laws, and rules ao regulations of t e San Joaquin Local Health District. (Signed) ------ ----- -----------------------------------------------(7- ------ Owner and/or Contractor) By:---- + ------------------------ - --- --- -------------------------------------------- (Plot plan, showing size of lot, location of system in r tion to wells, buildings, etc., can be pl ced on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------------------� -C'--'---- --- DATE-- �- ---- --------------------------------- /�---------------------------- REVIEWEDBY--------------------------------- -------------------------------------------- ----------------------------------------------- DATE----- BUILDINGPERMIT ISSUED------------------ ----------------------------------- ----------------------------------------------- DATE---------- Alterations and/or recommendations:------------------ -------------- --------------- -------------- ----------------------------------------- - ------------------------------------------------------------------------------------------•--------------------------------------------------. ---------------------- --------------------------------------- --------------------------------- ------ ---------------•-------------I------------------------------------------------------------------------------------ FINAL INSPECTION BY------ - ------- -------------------- I Date-------------- �:7/ G. SAN JOAQUIN LOCAL HEALTH DISTRICT Q 1601 E.Hosolton Ave. 300 West Oak Street 724 Sycamore Street 205 West 9th Street s .Y Stockton,California Lodi,California Manteca,California Tracy,California