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FOR OFFICE USE: _______________------------------------ -___ --------- APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date issued ________________________ ------------------------------- This Permit Expires'l 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 rdinance No. 549. JOB ADDRESS ANY LO 3�6y _ -----------------------------------------------------'- ----------------------------------------I----------------------------------------- Owner's Name--C1_1 -_ ----------- ------- --------•----------- ----- -----•-------------------------------- -----------------------------------. :_ -_._. Phone--------------------- - - --------------- Address----------------- ------ p---------------------------------------------------------- ----------------------------------------------------------------------------------------------- Contractor's Name_. '`1 ,7—- -S----------------------------------------- - ---------------------------------------------------- Phone----------------------------------- ------ - -- Installation will serve. Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: !------ Number of bedrooms Number of baths ---/--- Lot size __66.x_l.S __________________________.____._ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table __�f'ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[6-19ardpan ❑ Previous Application Made: (If yes,date___-_r.._..__..___) No New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No [ � TYPE OF INSTALLATION AND SPECIFICATIONS: F (No septic tank or,cesspool permitted if public sewer is available within 200 feet.) Septic an Distance from nearest well___________ __'Distance from foundation--------------------Material--------------------------------------_.________- No. of compartments----- - ---- ----- -------Size---------------•--------------Liquid depth------------------------.-Capacity--.-------------------- Disposal Field- Distance from nearest well-----------------Distance from foundation-------------------.Distance to nearest lot line___.__.____._____ N !I ❑ Number of lines-----------------------------------Length of each line----------------------.------.Width of trench----------------------------------- Type of filter material----------------------___Depth of filter material----.--------- --------Total length------------------------------------------- \ Seepage Pit: Distance to nearest well....~-...........Distance from foundation_00-_______ Distance to nearest lot line__!-...... � Number of pits_._._/---------------Lining material----_.%�4��---Size. Diameter--.._-3.3.- Depth-------— `_._____.____ �t\ Cesspool: Distance from nearest well_______________'`Distance from foundation-------------------.Lining material___...._.___.-______.___-_____..._. w ❑ Size: Diameter------'`--------------------- ------ Depth------- --------------------------------------------Liquid Capacity----------------------------gals, Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-.-___.___.________._____-----------_---- ❑ Distance to nearest.lot line ------------------- ------- ------------------------------------------------------------------------------- -------- -- ft I Remodeling and/or repairing (describe):---------------------------t i, ---------------------------------------------------•-- ----------- --------------------------------------------------------------------------------------------- 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, an rules and regu tions the San Joaquin,Local Health District. (Signed)--------------------- : ------ ------------------- ---------------------------------------------------------------------------------- --------(Owner and/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). e FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ -- �------- ------------------------ ---------------------------------------- DATE---------- _�� REVIEWEDBY------------------------- ------- ----------------------------------------------- --------------------------------------------- DATE----------------_- ----- ----------------------------------- BUILDING PERMIT ISSUED------------------------------------------ ----- - DATE------ -------------------------- -------------------- ---- ---- - __________________________________________..______._Alterations and/or recommendations•______.. r ---------------------------------------------------------------------------- - ------ ------------------------------------------------------------------------------------------------------------------------- -------------- --------------------- ------------- ---------------- ------ --------------------------------------------------------------------------------------------------------------------- ----------------- •------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:......._ -------- �Z �- Date ----0--`2/ ------- ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca, California Tracy,California 1