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FOR OFFICE USE: 0 i -------------------------------------------------- ------ APPLICATION FOR, SANITATION PERMIT Permit No. -------------- ---------------------- -------------- --- (Complete in Duplicate) -------.-- This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the wor ?herin c�scribed.This application is made.'in compliance with County Ordinance No. 549. ler X1 /� �/ JOB ADDRESS AND; LOC T Nom,--"r_fie------ Owner's Name -•-------------•---=-------------------------- ------------------------------------------- Phone---............................ Address-----•------ = j Contractor's Name---- •-- =• .a - ----`- ----- ----•------ Phone...............................•... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --- Number Number of bedrooms AR--- Number of baths Lot size -.__"_______________________ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table ,Z�ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam UE"C'lay Loam ❑ Clay ❑ Adobe ❑ Hardpan [I Previous Application Made:- (if yes,date--------------------) No New Construction: Yes E] No El�FHA/VA: Yes No j;,TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic flank;, Distance from nearest well_________________Distance from foundation--------------------Material---------------------------------------.._______- �jyw# 4P No. of compartments----------------------..-Size_----------------------------Liquid depth--- -----Capacity----------------- -- Disposal Field%, Distance from nearest well._,/',(�,�_--._Distance from foundation.s�10__ ------Distance to nearest lot line_,,e''®....... �� Number of lines----------_____ter------_____ ength of each line---- of trench_A___r--------------------_--- '40 ti+ Type of filter material-/_ r f yp ___ _ -______Depth of filter material-__ __ Total length_._OQ_ _________________________ Seepage Pit: Distance to nearest well___` Q_ _-___Distance from foundation__-�4-_-_-.Distance to nearest lot Number of pits---- __._________Lining material_ LA�'10 .Size: Diameter._.____.___Depthp!U._,f '' '_ P Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material------------------------------------- ❑ Size: Diameter-------------------------------------Depth-----------------------•------ --------------------.Liquid Capacity--- ---•-------- ----..gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--------------------------------- F] ________-._ ___-____-._____.__❑ Distance to nearest lot line------ - -------------------- Remodeling Remodeling and/or repairing (describe):------------ _ __ -__ ___ -- ---------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------- --------------------------------•-------------•------------------------------------------------------------------------------------------------------------------------------ ----------------------------- ----------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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 regulat' ns of the San Joa uin Local Health District. i (Signed)------------------------------------ ( Lor Contractor) -- BY: (Title)-- 2-..--- --- ---- --------- (Plot plan, showing size of lot, location of system in relati " wells, buildings, etc., can be played on reverse side). • FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----.__._. __ r__.._ �—- — ---------------------------------------------------------- DATE---------------_��--.---- --------------------------------- REVIEWED BY------------------------------- DATE BUILDINGPERMIT ISSUED------------ --------- ------------------------------------------------------------------ DATE----- ------_----------------------------- Alterations and/or recommenda+ions:--------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------- --------------------------------------------- -------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------- - ---------------------------------------------------------- -------------------------------------------------- ------------------------------------------------------------- ------------------- -------------------_-----_ ---------------------------------------- ----------------- ----'A. - ----- ------------- ------------------------------------------------------------------------------------------------------- ------------------- FINAL INSPECTION BY:.---- --- --- ------------------------ Date--S.---�--_C ----- ------------------_---------------------------- A JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California K Manteca,California Tracy,California M F.P.CO.