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FOR OFFICE USE: . _ _ - ----- --- ----- Permit No. APPLICATION FOR SANITATION PERMIT �� ------------------------------------------------------- ------------- -- -- (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 ad install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION... • --------------- .... 1..... . i a Owners Name Phone �' h= Address f e-_j�-- Contractor`s Name - .. - - -----••--------------------------------•-•----------------••---- Phone.............................. •.. Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I---- Number of bedrooms .�-". Number of baths j.... Lot size ____. . '�.��---•--• Water Supply: Public system ❑ Community system ❑ Private M Depth to Water Table G-A. it. rt I Character of soil to a depth of 3 feet: Sand ❑' Gravel ❑ Sandy Loam ❑ Clay Loam E4 Clay ❑ Adobe C? Hardpan ❑ P Previous Application Made: (If yes,dote------- ------------I No D9 New Construction: Yes N No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF:INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 240 feet.) Septic Tank:' Distance from nearest welly ____"____Distant from foundation. "�.`-_____.___.Nlaterlal. ............................................ �� No. of compartments_. --.-------_`.----Size__-�"�'_�.----...Liquid depth------�---------------Capacity.,�� . ----------- Disposal Field: Distance from nearest well!�"'_~._.Distance from foundation_Za-----------Distance to nearest lot line.. ....-- Number oflines.... `=---- ----- ------•--=-. Length of each line--/N------------------Width of trench. __..--1 ..._...:.. Type of filter materiae." Depth of filter material____� ___________.Total length____ ______________ `------"-•--.----- 46 Seepage Pit: Distance to,nearest we I______________________Distance from foundation_--.-___.__--.__--•.Distance to nearest lot line................. ❑ Number of pits----------------------Lining material-----------------------Size. Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well---------_-------Distance from foundation----------.___---...Lining material__.___."..-_______.----------------- . y ❑ ` Size: Diameter------------------------------p__ Depth----•-----------------------------------------�----Liquid Capacity-----•----------------------gals. __._Distance from nearest building -_-•________________. Privy: Disfiance from nearest well------------ ----------------------------- - Distance-to nearest lot line------- -------------------------•---*---•-•-----..................................................... Apt Remodeling and/or repairing (describe): �� ----- °-------------- --- t ---------•-• .. --------------- ...... --------------------- - -- ----------------------•---------------•-•----•-------------••------------------...------------------------...-----------------------•----------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat laws, and rules and reg lations of the`San Joaquin Local Health District. Si ned - ------------------------•----------------- {Owner end/or Contractor) --- -- --- . By------------- --------------------------------------------------------------------- --------------......-------_---._--------{Title) - ----------- (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 APPLICATION ACCEPTED BY ------------------------------- DATE----a o � ----------------------•-------- - ------- - - ------------------------------ REVIEWEDBY----------------------------------------------------------- --------------------=--------------------------------------------- DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED....------------------------------------ ------------------- —-------------------------------------- DATE------------------------------------------------------------- ( Alterations and/or recommendations:----------------------- •---------.... ----------._.....------------•----------•-------------------•----...----------•------- lr ------------------------------------*-------*---------- --••-----------_--- -- ----------------------- FINAL INSPECTION BY: ----------•---------------- Date/&--' -------------------------..._._ I SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 wait 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E6 9 REVISED 8.99 YM 5-6t AILA9