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FOR OFFICE USE: -i -------------- ----- ----- --------------------------- APPLICATION FOR SANITATION PERMIT Permit No. -5 --- ---------------------------------------- -- -------- (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. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND OCATION!� _ .. - . _. _ -------•• ....... Owner's Name__-- _ _ ------------------------- -- -------------------------- ----- Phone.Sr7+r_��lFas--------- Address--------- ------ -------------------------------- --------------------------•---•---------------------- --- Contractor's Nd'ne----------- ----- -- �-- - - ------------------------------------. Phone--------•-••--------------------•-- Installation will serve: Residence Apartment House E] Commercial E] Trailer Court ❑ Motel ❑ Other El Number of living units: ----____ Number of bedrooms __"Z—Number of baths --�___ Lot size --------------------------_____\-------------------------_- Water Supply: Public system ❑ Community system ❑ Private lf� 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: (if yes,date___________________) 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:–,„,ji,i..7. Distance from nearest well_________________Distance from foundation-------------------Material-----------------------------------------_-_.__. ❑ I No. of compartments--------------- ---------Size------- --------•-------Liquid .depth--------------------------Capacity-------------- -------- Disposal -----Disposal Field: { Distance from nearest well-----------.----4Distance from foundation--------------------Distance to nearest lot line.-_____._________ ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench------------:--------------------- Type of filter material---------_---------------Depth of filter material-----------------------Total length------------------------------------------ e it: { Distance to nearest well-----rr'_d_.......Distance from foundation----e�d ____-.Distance to nearest lot iine_S........... i S. '--- Size: l]iamef�r-- _ p [1 Number of pits---------/- -------.Lining material- � '� }� De th_... .Q Cesspool: Distance from nearest well-------------____DisCance-from'foundation--------------------Lining material----------.-____...._________-__.___. ; ❑ Size: Diameter--- .,--------- - ------------ Capacity----------------------------gals. � tt . / n Privy: Distance from neare.st'well_____________________________________- -----_....Distance from nearest building----------------------_-________.______- ❑ Distance to nearest lot lire-------------------- - ----------------------------------------------------------------------------------------r--------------------------- Remodeling and/or repairing (describe):---------- --- ----------------------------------------------------------------------------------------------•---- F ---------------------------------------------------------------------- ------------------------------ ------------------------------•------------------------------ ----------------------------------------------------------------- --------------------------------------------------------------------------------------- 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. (Signed)-------------------------------------------- ----- --------------- ---- ---------.----------------------------------------- _`EAwr�er and/or Contractor) or B y (Title)- ------- ---- --------- (Plot - - - (Plot plan, showing size of lot, location of system in relation to well buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION' ACCEPTED BY---- l k=,� --- ------------------------------------------------ DATE-.--//- 176 ------------ ---- REVIEWEDBY-------------------------------------------------- ------------- ---------- ----------------------------------------•------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED-------------------------------- - ------------------------------------------------------------------- DATE.---.------------------------------------------------------ I Alterationsand/or recommendations-------- -------------- ------------ - ------- --------------------------------------------------------•---------------•-----------•------------••-•----------- ---------------------------------------------- ---------------------------- ------------- ---------------------------- -- - -- - ------------------------- -------------------------------------------- ------------ ------ ll !- FINAL INSPECTION BY: .. _ Date../_/- ----'�� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hasellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California