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FOR OFFICE USE: ~ " /�61 -- ----------------------- J V -------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ..,1--•-------- .__ ---------------- --------------- ------------------------ (Complete in Duplicate) bate Issued ._.2�6/�� J -------------------------_--------_----------------------- 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. 106 ADDRESS AND LO ATEON------, _ ___ '------ ------- _-____�.._�____._____ � Owner's Name--------- -------------- Phone--/, --2-•�' ------- - - - - -- �---- I-_-•------------------------ Address--------------••----•-------- ----•-•--------- -•----•-------- -•-------•- - ....---.....---------------------------••-- Contractor's Name---------•------ ------------- ....... ----•-- ---------....----••------------- ------------- = ------ Phone----------------------------------- Installation will serve: Residence Z Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___oO__ Number of bed ooms , _-_ Number of baths _-_/_"Lot size ------- '-"_____________ Water Supply: Public system ® C_ommunity system El-;.Private ❑ Depth to Water Table _2r_pft. 5 Character of soil to a depth of3 feet: Sand ❑ Gravel ❑ Sandy Loam Ij Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,ciate__- -------_-------) No [j New Construction: Yes ❑ No ® FHA/VA: Yes ❑ Nog 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----r__4M---------Material---- -- i, � ---------- N -----.No. of compartments______.__._._"L,_.----Size-------- _,/'"� Liquid de th_____. _'Capacity � ----- . Disposal Field: Distance from nearest well.....ip!! ~-----Distance from foundation_____�-----.Distance to nearest lot line__-_-___wlr-_ ( Number of lines___________ ___________________Length of each line--------e- __ ------------Width of trench-----------'Z:___..______. _ a� Type.of filter material____� ___Depth of,filter material__-.,,mac'' _ ---- length____-__________�_ '__ __ Seepage Pit: Distance to nearest well.---------------------Distance from foundation--------------------Distance to nearest lot fine_..______________ ❑ Number of pits---------------------Lining material--------------------...Size: Diameter.---------------- ----Depth--------------.------------------ Cesspool: Distance from nearest well_---------------Distance from foundation---.----------------Lining material---.--------------------->__------_. ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. i Privy: Distance from nearest'well-------_-------_------------------------____-----Distance from nearest building_=__________________________..--- ___._- ❑ Distance to nearest lot line------------------------------- l' ' ------ loop Remodeling and/or repairing (describe):_________ t _ } _ ------------sl't---------------------------- ---------------------- ---------------I------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------- -------------------------------- Y r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State ws, and rule 4ad regulations of the San Joaquin Local Health District.(Signed) -- - --- -------------------- ------------------------------------------------------(Owner and/or Contractor) BY:----------------------- ---------- ---------------------------------------(Title)-------------------__--------------- .----. ----------- ---------------- ------------------------------- - (Plot plan, showing.size of lot,.loca+ion of system in.relation to wells, buildings, etc., can be placed on reverse,side). FO PARTMENT USE ONLY .' o APPLICATION ACCEPTED BY-------- --'--- ---- �------------=-------------------------- DATE----------- "z- '' • REVIEWEDBY------------------------------- ------------------------ ------------------------------------------ DATE-------- BUILDINGPERMIT ISSUED--------------------------------------------------------=---------------------------------=----------- DAT ------ --------------=------------------------------------ -- Alterationsand/or recommendations-------------- -------- -------------------------------------------------------------------•--------------------------------------------•------------------- ---------------------------------------- ------------- ------------------ ----------------- --------------------------------------------------------------------- ----------------- ----- FfNAL INSPECTION BY:----- -------Ll ----- --------------------- Date.--- . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-S9 3M 3-'83 F-P.CC.