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FOR OFFICE USE: ----- --------- ------------------------------- - r� ----------------------- --- --------- APPLICATION FOR SANITATION PERMIT Permit No. ...�-` _-_-___rJ_ ---------------------------------- --------------------- (Complete in Duplicate) / 0 This Permit Expires 1 Year From Date Issued Date Issued .- f 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. 4 JOB ADDRESS AND LOCATION _ _ - ------- Owner's -R-Owner's Name_ .... --------------- --- ---- ------ -Z ---- Address ---- r --- -------- ------- -------------------- P Contractor's Name.......... �_11 ----------- Installation will serve: Residence Apartment E] t ❑ E]Phone .._.. House ❑ Commercial Trailer CourMo#el Other El Number of living units: ___/___ Number of bedrooms 3.. Number f baths __ Lot size -_-_ __._ __ ___ ___________________ Water Supply: Public system E] Community system [I ate DPrivepth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Rt Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date____________________) No [" New Construction: Yes eNo ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 204 feet.) Septic Tank: Distance from nearest well_f__,iS�____...Distance from f undation__.___1_0--- _._.Material____5:�1�-�.<.L.�_____________ No. of compartments -Size____+ QQ p � � � �-=7---1(s��Liquld depth------ - � - Capacity--�-'�--DG----- Dispo Field: Distance from nearest well___-5.U_-}Distance from foundation___1_0A---------Distance to nearest lot line.s�.�.. Number of lines-------- _ _____ - . Length of each line 'Y .=_7��_ Width of trench----- .�.-_-_--- s, Type of filter material_ �_ ,_______Depth of filter material- " __--I ____.___Total length_ __--_______________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line________________ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Dept h_________.._______________------ Cesspool: Distance from nearest well-________________Distance from foundation------------------- Lining material__--__-_--___-.__-________________.__. ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity---------•---•------.------gals. Privy: Distance from nearest well-----------------------------------_-------------Distance from nearest building_______.______________________.____.___--- ❑ Distance to nearest lot line---------------------------------- Remodeling and/or repairing (describe)----------------- -------------------------•------------- --•-----•------------------- ------------------------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - - ----- ----------------------------------------------------------------------------------------------------------------------------•--------...---•----------------------------------------••-----I---------------------------- I hereby certify that I have,prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. -- --- - - ------- ------------------------------ ---------------- a d or Contractor (Signed) _ ) BY:---------------------- 1---------- ----------- (Title)----------------- -''----------- --- - - -------------- (Plot plan, showing size of lot, location of system in relation +o weI s, buildi gs, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ _ G�� ------------------------------------------- DATE----�ZJ_---G`�-------------------- REVIEWEDBY-------------------------------- ------------- --- ------- ------ ------------ ---------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED--------------------------------------------------------------___---------------------------------- DATE------------------------------------------------- ----- Alterationsand/or recommendations:--------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------- -------- ------------------------------------ -------------------------------------------------------•-------------------------------------------------------•-------------------------------- ---------------------------------•-------------------------------------------------------------------------------------•------------- -----------------------------------•---•-------------------------------•----- -------------------------------------- ---------- -----•-------- ------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------- --------------------------------------------------•---------------------------------•-- -•---------- -----------------------•------------------------ ------------------------------------------- FINAL INSPECTION BY____ -t r-_,�---- -- -------- - Date.... / •r------------------------------------------- _________ _ r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ha:eltan Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California C5 9 REVISED B-59 3M 3-'63 F.P.DD. 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