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FOR OFFICE USE: _ ---------------- --------------------------- -------- APPLICATiON FOR SANITATION PERMIT Permit No. (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 A D LOCATION_,-&__0-k---. `' ----- _.f` Owner's Name------ -- ---------------------------------------------------------------- - Phone Address----� -----y__ :---- ----•----------------------------- Contractor's Name-------------- 1'� ----------------------- ----------------------------------------------- Phone---------------------------------- - Installation will serve: Residence 04 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms _- Number of baths __./___ Lot size ---------------____________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. i Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam K Clay Loam ❑ Clay ❑ Adobe D' Hardpan ❑ Previous Application Made: (If yes,date--------- -._--_..._I No IR 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 frominearest well-----------------Distance from foundation------------ Material------------------.-----------------------..____. ` ❑ No. of compartments--------------------------Size--------------------------------Liquid depth------------ -- ---------Capaci.ty..----- --------------- Disposal Field: Distance from nearest well p�istance from foundation_f�-U_- Distance to nearest lot line__ Number of lines----------------j\- -----------Length of each line-__ --- ----Width of trench.X 4r __.____--_---- Type of filter material _/.-�v ---Depth of filter material_... _ '_---._ g Tota4 length --2-Q_ ---=------------ ----- Seepage Pit: Distance to nearest well-- Distance from foundation__________________ Distance to nearest lot line--------------- p --Linin r -------De th Dumber of its.--�--------------- g material-- ---�--L'�.�Size: Diameterr_ - -- - -- p --------------------- d Cesspool: Distance from nearest well-------------___Distance from foundation---.-------_._.._...Lining material-----------------------------.------- ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity_. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--------------------------------------- I ❑ Distance to nearest lot line------------------- --------------------- --------------------:- ----------------------------------------- ---------------------- O Remodeling and/or repairing [describe:_-- ;✓ ,i---- � --------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------- - F -----------------------------------:------------------------- ------------------------------------------------------------ --------------------------------------------------------------------------------------_...{.. hereby Cert' that I have prepared this application and that the work will be done in accordance with San Joaquin Coun y I he y P P PP ; ordinances, Sta I s, and rules a regulations of the San Joaquin Local Health District. .4 F r � (Signed)------- ----- ------- ------------ ------ --- ------ - _z ---------- -- --------------------------------- ----------------- ----(Owner and/or Contract ------ ---- - --- - ------ ------------------------ (Title) - --- -----...-- (Plot plan, showing size of bt, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- --------------------------- DATE__ -- DATE----------------------- --- ------------ - REVIEWED BY - I BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:------------------ ---------- ------------------------------------------------------------------------------------------------------------------------------ ------------------------------------ - - ---- ------- ----------------------------- ------- ------------------------------:--------------------------------------------------------------------------------•----------- -------------------------- ---------------------------------------------------- -----------------------•-------------------------------------------------------------------------------------------------•---------------- FINAL INSPECTION BY: -• ----------st= Date - y ` SAN JOAQUIN LOCAL. HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Mantecar California Tratyr California F•.P.Gd.