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------------- F = -------- -- --------- �j�/ .------ :- ---_2� �`? :-------_ APPLICATION FOR SANITATION PERMIT Permit No. -�`�!_..T.- - --------- -- ----- -- ---------- ------------ (Complete in Duplicate) -- --------- ---- -- --- This Permit Ex ires 1 Year From Date Issued Date Issued _ .:- I 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. /5-49.. JOB ADDRESS AND LOCATION Owner's Name------- ~ - Phone -------------------------_--- Address ,9 3 ------------------------- l 3 t� E --------------------------------------------------------------------------------------- Name-------------------------- Installation ---- -- v... -----••-- ------------- -------------- Phone----------------------------------- Contractor's Installation will serve: Residence//©�partment House E❑ Commercial ❑ Trailer Court E] Motel Other El l-- Number of living units: --- - Number of bedrooms _-. - Number of baths c2. Lot size .-�� O�--------_ ------------ Water Supply: Public system X Community system ❑ Private ❑ Depth to Water Table FQ.- ft. Character of soil to a depth of 3 feet: Sand ❑ -Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobeo Hardpan ❑ f Previous Application Made: (If yes,date---------------- Nox New Construction: Yes [❑ No)4 FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ep Tank: Distance from nearest well-----------------Distance from foundation--------------------Material No. of compartments - Size---------------•--- ------------Liquid depth------------ - ----------Capacity------------------- -- Disposa Field: Distance from nearest well./�± -_Distance from foundation-/ ..........Distance to nearest lot line`s------------r''L Number of lines._- j----------- Length of each line___l-4 Q --__-_--._Width of trench.-.--! - -• ----------------- Type of filter material-5- I ---Depth of filter material----/9............Total length--------------------------------------- Seepage -__.-.---------_/ -- --_Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_--------_•----- y ❑ Number of pits---------------- -----Lining material---------------------- Size:.Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material--------------------------------_---. !y ❑ Size: Diameter --------Depth------------------------------ ---------------------Liquid Capacity- --------------------------gals. r Privy: Distance from nearest well:------------------------------------- --------- from nearest building-------------..------___--------- ❑ Distance to nearest lot line------_:-_------..---.-----_ 'IV ,a Remodeling and/or repairing (describe):------------------------------------------------------------------------------------------------ -------------------- - . ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------- o ------------------------------------------------ -------------------- ----------------------------------------------------------------------------------------------------------------------- ---------------------------- - 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 reguI tions of the San Joaquin Local Health District. (Signed)------------- 0—L ---- -------------- -- - �---------- __-------------------------------------_--...(Owner and/or Contractor) By:-----------------------------}-----••--•----------------- - - ------------- Title)------- - ( (Plot plan, showing size of lot, location of system in relation to ells, buildings, etc., can be placed on everse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY {•+•.. �ac�,` _ - ---------------------------------- ----- DATE------- , � REVIEWED BY ------------------- DATE BUILDING PERMIT ISSUED------------- ---- ----------------- ---- --- ----------------------------- ----------- DATE Alterations and/or recommendations:----------------------- - -------------------------------------------------- --------------------•-------------------------------•------------------- ------------- 1 FINAL INSPECTION BY------ -- ------------fNJOAQUIN ---.._ Date...................... - --------------- -s----- � --- LOCAL HEALTH DISTRICT 1641 E.Hazelton Ave. 30Street 124 Sycamore Street 205 West 9tt,Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.0 n.