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FOR OFFICE USE: t --------------------------------------------------------- ------------------------------------------- ------------- APPLICATION FOR SANITATION PERMIT Permit No. . _____ ---------------------------- --------- (Complete-in Duplicate) Date Issued --- -------------- ----- -----------------___---- This Permit Expires f Year From 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 compl' nce "th County Ordinance No. 549. J013 ADDRESS AND LOCATION..__2/- _,I?. ✓__--4,6____ -1"A! _ ___ ---- � -- -- !-x -- -.--.... -_ ! - - --------- ----------------------- Owner's Name-------- --- Address---- .....j------- -�-------4-j------------------_-- Contractor's Name.---: } '1 A----------------------- ----------------------------------- ------- ----------------------------------------------- Phone------ -----------------•---------- Installation will serve: Residence4] Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _- .-.-_ Number of bedrooms -------- Number of baths-------- Lot size ----- ___ ________ --- ---- ------- ______.____________-__ Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table ------ _ 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 ❑ 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.) Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material -----------_----- -___-__-____--.-___________- No. of compartments------ ------------------Size------------------.. -----------Liquid de th___-____- ------- --------Capacity-,,.-, Disposal Field: Distance from nearest weli_e-Lr. I-----Distance from foundation.... c?4------Distance to nearest lot line`r_�__....__. Number of lines ------ _-__/___--------____._._-.__Length of each line__ _/---____---_--_--.Width of trench---�_��_n___._____..--------- Type of filter materiat---------------Depth of filter material---- _9-4----------Total Seepage Pit: Distance to nearest well______________________Distance from foundation--------------------Distance to nearest lot line-----.____-_----_ ❑ Number of pits--- ------------------Lining material------------------ --- Size: Diameter-----------.--_--------Depth--------------------------------- (.I Cesspool: Distance from nearest well ________________Distance from foundation----------------- ..Lining material__---_-_-.-:______--_-_____-.___-_-_ ❑ Size: Diameter- -- --------- ----- -------- -------Depth--------------- -- ----- - --- -- --------- --------Liquid Capacity-.--------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----------------------------__-________-. v ❑ Distance to nearest lot line --- __-------------- - ---------------------------------------- Remodeling ------------------------------------- Remodeling and/or repairing [describe): r11'1..-6'1.--- -------------------------- ---------- - -------- --••---------------------------------------------------------------- ------- -•--------------------------•----------------------------------------------- - --------- 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, and rules and regulations of the San Joaquin Local Health District. (Signed)--- •• - (Owner and/or Contractor] By:----------------- -------------------------------------- ------------------------------ ------ -(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 BY__ _ -._-_- _ , _ __----_ -------------------------------------- DATE---- ...... 47-------- --------------- REVIEWEDBY------------------------------------ ----- - ---- ----- - ------------------ ------------------------------------------------ DATE---- BUILDING PERMIT ISSUED - ---- -- --------------------------- -------- ------------------------------------------------------ DATE._.-. - Alterations and/or recommendations:----------------- ----- -__------------ ------------------------------ ---- -----------------•------------------------ ----------------------- ----------------------------------- -------------------------------------- ----------------- ------------------------ --------------------------.---- -- - ----- --------------------------- .... -------------------------------- ------------------------- FINAL INSPECTION Date-If'"Z�� ------------ .......... --- ----------------------------------- ------------------ - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Slorkton,California Lodi. California Manteca,California Tracy,California E.N.9 2M 1-67 Vanguard Press "�