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r FOR OFFICE USE: r-3 , eo;3c� ,rrr ----------------- - --------- APPLICATION FOR SANITATION PERMIT Permit No. ----------- - --- ------------------ -------------- (Complete in Duplicate) Date Issued This Permit Expires 1 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 compliance with County Ordinance No. 549. I � ----------- ---JOB ADDRESS AND LO TION. Owner's Name- ��f'-'---------------------- ----------------------- Phon ......-•--------- --------------- Address . ----• ------------------- ---------------•---------- Phone.. Contractor's Name-.__............. -_`�� Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [] Number of living units. _/--- Number of bedrooms , - Number of baths .A__ Lot size ' _-'--------------------- Water Supply: Public system ❑ .Community system ❑ Private B-1Dpth to Water Table 46p ft Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 8000Clay ❑ Adobe ❑ Hardpan ❑ I Previous Application Made: (If yes,date.t,_--_._,...___..I 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:e Distance from nearest well-----------------Distance from foundation:-------------------Material.........-.---.-___.._.---------------.-.._---- �l �fKe 'Noof compartments------------ -- ---- ---- Size--------------------------------Liquid depth------------------------._Capacity----------------------- Disposal Field: Distance from nearest well-----------------Distance from foundation--------_.-...------Distance to nearest lot line....----._.-.--.- (.� fl4 Number of lines-----------------------------------Length of each line----------;"_----------------Width of trench.----,------- ------------------- Type,of filter material--_.___----------------Depth of filter material_____..,.-----------Total length-------------------------------------- Seepage Pit: Distance to nearest well__lle --Distance fro foundation__. ..Distance to nearest lot line--f 2f'.. Number of pits......_.------'_-----Lining material._ a :-Diameter___. ..- ! 5 Cesspool: Distance from:nearest well........... .....Distance from foundation------------._.....Lining material------------------------------------- ❑ Size: Diameter--------------------- --- -----4'=..Depth---- ------------------------------------- ---Liquid Capacity-- ------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------------------------_ ❑ Distance to nearest lot line_-. ------------------------------------------------------------------------------I------------------- RemodelingOe - - ----------I and/or repairing ------_-___-- ------------------ p g ------------------------------------------------------------•--------------------------------- ------------------------------------------ --------------------- -----------------------------------------------------------------------------------------------------------------------------------•-•--:----------------•-------------------------- ----------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County :1 ordinances, State laws, ancl rules and r lations Ef the San Joaquin Local Health District. (Signed)-- ---------------- - -- ��- ---- --`�.,-'�- - - - - ------- --------- -- - ------- ---- ------------- ---------I--------------------(.Qwaep-eed�or Contractor) �.BY: ---------------------------------------- ------- ----/ (Title)- (Plot plan, showing size of lot, location of system ' elation to wells, buildings, etc., can be placed on reverse side). } FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- - -------F -------------------- ---------- DATE- REVIEWED ATE REVIEWED BY--------------------------------------------- - ---------------------------------------------------------------------------.- DATE----- -------------•---------------------------------------- BUILDINGPERMIT ISSUED----- ------------------------------------------------------------------------------------------------ DATE--------------------------- ------ Alterationsand/or recommendations--------------- ---------------------- --- ----------------------------------------------------•--------•------•----••-------.--.-•--------------------------- ---------- I ---------------;---------- -------------•---------------------------------------------------------------------------------------------------r-------- ------- ----------------------------------- --------------------------------------------------------------- ------------•-•----------- ---------------•------------------------------------------------------------------------- ------------------------------ ----------------------- --------------- ------------------- ---------------------- ------------ ------•----- •-•--------------- ------------------------------------------ FINAL INSPECTION BY:._..... _ . . --- - -�- -- ---�� '- - ------------ Date -----� ----•-�-- ----�-� -----------t---------=7---- SAN JOAQUIN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.karetton Ave. 300 West Oak Street 124 Sycamore Street' 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.0 0. i � '�