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FOR OFFICE USE: �. • ' -------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .. ......7 ------------------------------------ ------------------ (Complete in Duplicate) � p ----------------------- --------------------------------- 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 AND LOCATION -------( .rr f�- L-------------------- ----------------------------- Owner's Name----- /1�- _: ........ Phone, off.,.. Address 4 . .. ` ContractorsName_---------•--- ---------------------------------- --- ----------------------------------------- Phone..................:................ Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ._/--- Number of bedrooms ._") -- Number of baths .-/___ Lot size ___ ��_'__ ��._-_-_ --- --- --•-------- -------•- Water Supply: Public system C] Community system Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ FGravel ❑ Sandy Loam ❑ Clay Loam ❑ 1cy ❑ Adobe Hardpan ❑ \ Previous Application Made: (If yes,date_________________ ) No ❑ ❑ ❑ - New Construction: Yes No FHA/VA: Yes No 4 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---__r'-_-Distance frorn foundation1 ___Material___------ 1/.D ................./� [ No. of compartments_____----? Size__ '�_ _,.__Liquid depth____ Capacity...4Z�Af!.� Disposal Feld: Distance from nearest well....._�:__._Distance from founda+ion-_--.!_../_ .._-_.Distance to nearest lot line.__.__�7 ( � Number of lines-----------------------------------Length of each line-----------------------_----.Width of trench----�.-- --- -------------•-- Type of filter material-_ �rc l'-___Depth of filter material______ZZ ---------Total length------„2!.__-•_ _ ______________ Seepage Distance to nearest well____--__•______-_'�Distance�m fou dation___- _��_---.Distance to nearest lot line...._,`.. Number of pits----------/--------Lining'material___t ��_� .Size: Diameter-------- ..Dept h----------- ,5._................. Cesspool: Distance from nearest well-----------------Distance from foundation---.----------------Lining material------------------------------------- 0 Size: Diameter......--------------------------------Depth-----------------------------------------------------Liquid Capacity--.---------------------._._gals. 1 Privy: Distance from nearest well-------------------------------------------------Distance from nearest building______._.-...__..._.._________________._. ❑ Distance to nearest lot line-------------------------------------------------------------------------------------------------•----- t Remodeling and/or repairing (describe):-------------------------------------------------------------------------------------•----------.--------------- -------------------------------------------------------------------------------------------------------------------------•---•---•--•--•---------•---------------------------.-.------------------------------------- ------ t I I •-----------------------------------------------------•--- •----••------------------------------------------•---------------------------------------------------•---•-•---••------------------•---------------------------- I hereby cert' y that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State aws, and rules an regale#ions of the San Joaquin Local Health District. r (Signed '�^ - ----------------------------- -.------------------(Owner and/or Contractor) By:---------------------------------------_------------------------------------------------•----------•--.......------•-••--------(Title)-------------------------------------------- - -- -------------- (Plot plan, showing size o ot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FQR DEPARTME1f4T USE ONLY APPLICATION ACCEPTED BY---- / ------ •--- DATE � ti REVIEWED BY--------------------- - --�----- ------ ------------------------------- DATE--- ............. -------------------------------•---•--•- BUILDING PERMIT ISSUED--`-................. ---- -- ------------ - DATE---------------------------------------------------------- e and/or recommendations:___ __e ._.._ ------ -------------------------------------------------------- �_. --- ---------------------------------------��----��---._..-._..... - -��.................................--------•--------------------------------...................... -----------------------------------I-------------------------- ------------------------- •---•---------------- FINAL INSPECTION B Date- ------------------------------------ SAN J AQUIN 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 ES 9 REVIsEo B-59 YM 5-61 ATLAS