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FOR OFFICE :------------------ --.-- APPLICATION FOR SANITATION PERMIT Permit No. _rC� ----------- ----- - --------- --------- ----- -------------------- (Complete in Duplicate) _ 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,1& ..1'.1__-/rV----L114�-- 1: -_? /4 ------------------------------------------- Owner's Name.----- - Phone------------------------ ----------- ------ -------- -- --------------------`------------- ------------- Contractor's Name---o------------------------------------------------------- -------------------- -------------------------------------------- Phone---------------------------------- Installation will serve- Residence R3 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -1----- Number of bedrooms _z-___ Number of baths ---k... Lot size _-- -------------------------------------- Water Supply: Public system ❑ Community system ❑ Private ® Depth to Water Table"QA_ ft. V' Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ® Clay ❑ Adobe ❑ Hardpan JM if Previous Application Made: {lf yes,date-----------.----.---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: Distance from nearest weld-----------------Distance from foundation----------------.__Material____----------_-----------------------.____.__. ❑ No. of compartments---------------------------Size--------------------------------Liquid depth--------------------------Capacity...-------------------- Disposal Field: Distance from nearest well.-7-S--------Distance from foundation__'`'__®--..----.__Distance to nearest lot line_ -----.--__- Number of lines---------I-------------------------Length of each line-----.I_-v----_--------.-Width of trench.... ---��------------------__ t Type of filter material___b3-,--------------Depth of filter material-_1_'�_'...___...___Total length-----I_srn---____-----_---.-_----_----_ Seepage Pit: Distance to nearest well___tSO----------Distance from foundation---I------__.---- Distance to nearest lot iin06_-.---_-..__ Number of pits.------►--------------Lining material__ ..........Size: Diameter__.._j_$"_.----.__Deptn__3-4______________ ! Cesspool: Di0ance from nearest well-----------------Distance from foundation---------------------Lining material--------._._--_--._ ❑ Size: Diameter-------------------------- -----------Depth---------------------------------------------r------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building____-_---_-----_----_-_--_-___--..__..._. j ❑ Distance to nearest lot line---------------------- ------------------------------------------------------------------------------- --- ---- Remodeling and/or repairing (describe):---- ------ _ --------------•-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------- - - ------------------------- ----------------------------------------------------------------------------------------------------------------------------------------- - ---- -------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, to laws, and rules and regulations of the San Joaquin Local Health District. (StgnedJj - l - (Owner and/or Contractor) - (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 A APPLICATION ACCEPTED BY--- - DATE_6_-'.2--3--------------------------------------------------- - - REVIEWEDBY----- ------------------- ---- ------- --- ---- ---------------- ---------------------------------------------------------- DATE----------------------------- ------..---- ---------------- BUILDING PERMIT ISSUED-------------------------------- -----------------•--------------------------------------------- DATE---------------------- --- --------------------------------- Alterations and/or recommendations:-----------------•- =•----- -----------------------------------------------------•-------------------------•-----------------•------------------------------ --------------------------------------------------------------------------------------------------- ------------------------------------------ ---------------- ------------------------------------------------- ------------------------------------------------------- ---- ------------------ ----------------------------------------------------------------------------------------------------------------------------------- -----•--------------- -------------- ------------------------------------------------ ---------------------------------------------------------------------------------------------------------- --- ---------------------- - ----------- ------------------------ -------------------------------------------------- ------- ------------------------------------------------------------------------ ------------------ - ----------------------------- FINAL_ INSPECTION BY; _________________ Date------------------------------C SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Harellon Aye. 300 west Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California _ Lodi,California Manteca,California Tracy,California l