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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. JOBADDRESS AND LOCATION_ -------------------------------------------------------------------- -------------------------------------------- Phone------------------------------------ Owner's Name_ --------------------------------------------------------------------------------------- Address---- ------ Phone.. Contractor's Name-- -- ------------------- Installation will serve: Residence [Z]- Apartment House E]� Commercial' E] Trailer Court C3 Motel L] Other El � "- - --- ---------------------------- Number of living units: __/--- Number of bedrooms _S--- Number of baths Lot size / Water Supply: Public system F-I Community system Private El Depth to Water Table _i:0tiff" Character of soil to a depth of 3 feet: Sand R Gravel 171 Sandy Loam El Clay Loam ❑ Clay [j Adobe FT�Harclpan E] -------) No [g],' New Construction-, Yes E] No [e� FHA/VA: Yes R�— No El Previous Application Made: (If yes,clate_------- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tanl:- Distance from nearest well-_____-_ ._____-Distance from foundation--------------------Material------------------------- ---------------------- Aq�V!4No. of compartments---------- -------- .---Size---------------------------:---Liquid depth------ -------------Capacity--------------- ------- X- Disposal Field: Distance from nearest well....!_' __Disfance from founclation---IZ9---------Distance to nearest lot line-,_$ -------- - I/ Is.........g -------- ----------------------- A Number of line ------- Length of each ......Width of trench-- 9W I/ length----40 g12 ---;t ----Depth of filter material---Z T aterial- 11110 ------Total --------------------------- Type or filter m 'dl�l -- I e from founclation--------------------Distance to nearest lot line_.____-__________ Seepage Pit: Distance to nearest well____________ ---------Distan(� 'K6,mber of Pits----------------------Lini;ng material-----------------------.Size: Diameter-----------------------Depth--------- ------------ Cesspool: Distance from nearest well-----------------Distance from foundation---------------------Lining maferial------------------------------------ ls El Size:;Diameter------------------ ------------------Depth----------------------------------------- ---------Liquid Capacity.-------------- . - ga Privy: Distance nearest well-------------------------------------- ---- ----Distance from nearest building-----------------_--------------------- ❑ Distance' line--------------- ---------------------------------------------------------- ,0- earesf lot ----------------- - ------------------------------ ------------- nq Remodeling and/or repain describe):------------/4--�__ - ---------R.,Z,5c�------ ------ -------- ----------------------------------------------------157---------------------------------------------------- ------------------- --------- ---------------------------------------------------------------- --------------------------------------------- -------- ------ ------------ -- --- ------------ ------------..............._r-------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------- -- 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. 07 (Signed)----------------------------------- /69/1�------------- --------------- ---- --- --------- -----------------------------(Qwmw!� /or Contractor) �Aa--------------(Title) Sy:---------------------------------------------------------------------I----------- (Plot plan, showing size of lot, location of system in rel to wells, buildings, etc., can be placed on reverse side). OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__._._.. 9-- - —------ --- -------- - DA TE------ ----------- -------- -- -------------------------------------- REVIEWED BY----------------------------------- ------------------------------------------------------------------- --- - DATE BUILDINGPERMIT ISSUED--------------------------------------------------------------—-------------------------------------- DATE-------------------------------- --------------------------- Alterations and/or recommendations-------------------------------------------------------------------------------------------------------------------------------------------------------I ------- ----------------- --------------------------- ------------------- -----------�:_----------I- -------------------------------------------------- ---------------- -------- ---------------------------------I----------------- - ---------------------------------------•---------------- -----------------------I----------I—---------------- -----------1-1------------------------------------------------------------------------------•----------- - -----------------------------------I----11-----I----I---------- --- - -------- - ------- ------- ----- - ------ ------ --------------------I------- --------- ------- --------- ----- ------------- ------ - ------------ ------------ -------- �------ - ------ ----- - ------------------- --------------------------------------------- --------------- ---------------I------------------------------------ --------- ---------- ... FINAL INSPECTION BY:. Date ---------x-------------- ------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haisiton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.C O.