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FOR OFFICE USE: ------------------------------------------ ----- --- 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. «r This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AN � a ;J3?d---F-t--' Owner's Name------ ------------------------------------------ ------------------- -- ---- Phone--------G '-- •--------------------------------------- •--------------- --------------------- --- --------- -------------- Address.. ----- --- v Contractor's Name -------------- -t--- `- ----------------------------------------- Phone----------------•--...------------- Installation will serve: Residence Ef",Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ I , l Number of living units: _ ---- Number of bedroom____ Number of baths /____ Lot size ___ .'__. ._ __ ---------------------.._ f€ 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: -IIf yes,date-----------------;...) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: t -(No septic tank or cesspool permitted if public sewer is available within 200 feet.) r t � - Septic Tank: Distance from nearest well-------------- Distance from foundation-------------------Material-------------------------..-__.-__--__-...____-. ❑ No. of compartments--------------------------Size---------------------------------Liquid depth--------------------------Capacity....----------------._. Dispo Field: Distance:from nearest well....4Fi-_._Distance from foundation----ZCJ-_-.......Distance to nearest lot line-S__-._____ r` Number-of.lines--'--------/----------------------Length of each line-----Fda-`---------------Width of french----:'A-_------------------ ------- Type of filter rnateriai____'__cg_1Z----------Depth of filter material------f_f'__'----__Total length__-.?-o_------------------_______ Distance to nearest well_____.!_!?a__-_-_Distance from foundation------ .___.Distance to nearest lot iine..s--______ o _ a. _..- .. _. n Number of pits ------�----------'Lining material-----�"-R-'_-_----Size: Qi.a�w+e#er_�----�-�a___-.Depth_..--��--------------------- Cesspool: Distance .from nearest well----------------- from foundation-------------------- Lining material_____________________________________El _ 0 Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity----------------------------gals. d ._Distance from nearest buildin Privy: Distance from nearest well _------------- 9 -------- - ❑ Distance to nearest lot line----------------------- ---------------------------------------------------------------------------------------------------------- - Remodeling and/or repairing (describe}-------------- r" rr -------------•--- .- r. _ ----------------------------------------------------------- ICIF -------------------------------------------------------------------------------- ---------------------------------------- ----------------------------------------------- ------------------------------------- --------------- ------------------------------------- --------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------- 1 hereby ce . y that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, ate}a , , and rules and regulations of the San Joaquin Local Health District.! (Signed}-6, ingo -- ----- ----- --- ------ -------------------------- -------------------------------------------- and/or Contractor) Plot .Iasize of lot, Eocation of stem in lotion = - (Title)-----------on ------------------------- ----- ------ ----- -- -'--- -- ----------- -- ( p y Wto wells,Vu—ildings`, etc.,can'be-placed on reverse-side): R---- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- -- - b ---------------------------------------------------- DATE -- -------------------------------------------- REVIEWED -` G------------------------------- REVIEWEDBY------------------------------------- ------- ----------------------------------- ---------------------------- ----- -----•--- DATE-------- --- ---------------------------------------- fBUILDING PERMIT ISSUED---------------- ------------------- --------------------------------------------------------------- DATE------------------------------------------------------------ Alterationsand/or recommendations:----------:-- -------------------------- -------------•-----------------------------•--------•- •-- ------------------_---------------------------------- -------------------------------------------------- ------------------------------------------------- ---------------------------- ------------------------------- ------------------------------------------------ FINAL INSPECTION BY: -- -- - ---------- ---------- Date. -� --------------- ---------------- -------- --------------------- ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Huxetion Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California �•'� 'r r.R,c o. / f