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FOR OFFICE USE: ------------------------------------------- ----4 �� --------------------------------------------------- ----- APPLICATION FOR SANITATION PERMIT Permit No. __6......-.._..-..._._- --------------------------------------------------------- (Complete in Duplicate) Date Issued ---------------------------- This Permit Expites71 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. 1 This application is made in compliance with County Ordinance No. 549. f/ c `1: JOB ADDRESS AND LOCATION `- --�--g----------------------- ---------------- - ------------- - Owner's Name_______ _ _.____...,___ Phone___ .3.1 •--------- -- - -- --------------- Address__ 34 - - . - Contractor's Name--------------------------- -----_-_------•---------------------------------------------------------- ---------------------------------- Phone----------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial JT�Trailer Qettr Motel ❑ Other ❑ Number of living units: ___!___ Number of bedrooms _g,___._ Number of baths A_____ Lot size ;I--------------------------------------------------- Water --------+Arm_______________________________Water SupplY� Publics stem ❑ CommunitY system D ft.Priva+e De fln to Wafer Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay Rr Adobe ❑ Hardpan ❑ Previous Application Made: [If yes,date-------- ___) No EB, New Construction: Yes R' 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_._7�__----Distance from foun tion___1 _____-Material_______________________________________________: V� No. of compartments----------2----- -----Size.......... Liquid depih--------------------------Capacity----------- __- -- ` Disposal Field: Distance from nearest well___®_______Distance from foundation----- ------ ---- Distance to nearest lot line____I_U�__ ❑ Number of lines-------_—------------------- ---Length of each line---------ed..________.__.Width of trench-__34--------- ---..--------- Type of filter material_2_��1l _n__Depth of filter materiaLl .............Total length____�6a_J___-__._____________._ ! Seepage Pit: Distance to nearest well____________________Distance from foundation____-_________-___.Distance to nearest lot line______..__-__..__ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth-.-------------------___-_------- 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----------.__._-_______________-----_._._. ❑ Distance to nearest lot line---------------------------- --------------- - ----------------------- -------------------- -------•---------------------------------------- Remodeling and/or repairing (describe)----------- ------------------------------------------------- •------------------------------ ' ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------------------------------------------------------------•--------------------------------•-------------------------------------------------------------------------------------------------------------- - -------- -- u I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, S+ate laws, and rules and regulations of the San Joaquin Local Health District. (Signed) --- - - -- (Owner and/or Contractor) By:----------------•--..--------------------------------- -- ----------- -------------------- --------{Tale)----- - -------- -------- ----• ........... .----- ----- (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------ __-- '- _---- -1�---.7------------------------ REVIEWED BY --- DATE-----.4- `6 ------------------ BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------------------------------------------------------------- Alterations and/or recommendations:--------------------------------------------------------------------------------------------------------------.._..-------------------------------------------- ----------------------------------------------------------------------- ------- ------------------------------------•------------------------------------------------------------------_-------------------------------- -------------------------------------------------------•--------------------------------------------- -------------------------------------------------------------------------- ------------------------------------------ -- ------------------------ ------- ------ - --- --------------------- - ------ - - --------- -------- --------------------------------- ---------------------------------------- ...........................-- ------ FINAL INSPECTION BY:--- -------?` ------- Date. YIIP�9!` - - - ------ -------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1661 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California