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FOR OFFICE USE: -- --------------------------------------- ------------------- ------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. /�_.J5.,-2— (Complefe in Duplicate) ------ --------- --------------- -- --- This Permit Ex fires 1 Year From Date issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to con con install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION_..__!'' - Owner's NameYrte./-_---•---`iG�f•- - ^p'_.------•---- ----------------------- ------------------------- ----------- Phone--- Address- = ` 'r --------------------------•-----------------•- -----------•--•-------------••--------------- Contractor's Name _ _ ----------•----•-------------------------- --•-- -------------- ------------------------------------ ------ Phone-..------------------------------- Installation will serve:- Residence M Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ►_----- Number of bedrooms Number of baths I------ Lot size �e Water Supply: Public system(� Community system E] Private E] Depth to Water Table _"].4_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Q -Clay'Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date......_-------------I 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: Distance from nearest well-----------------Distance from foundation--------------------Material El No. of compartments------ -------------------Size---------------------------- ---,Liquid depth-------------------------- CapacitY------ •-------------- Disposal Field; Distance from nearest well_______________ Distance from foundation---------- ---------Distance to nearest lot line--------- �j❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench.--------------- N . ------------------ Type of filter material-------------------------Depth of filter mai-erial________-----_-----__To#al length______.---___________-__---___ Distance to nearest well---I+ -_---Distance fro foundation___________________Distance to nearest lot line_s .___- -----_ Number of pits----- ---------------Lining material_--------.Size Diameter__� -,-------Depth_-7- ------ Cesspool: Distance from nearest well------------------ from foundation;________------____.Lining material------------------------------------- FJ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity -------gals. S. Privy: Distance from nearest well___---.._-___________________________ ________-Distance from nearest building ❑ Distance to nearest lot line Remodeling and/or repairing (describe)--------------------------------------------------------------------------- ---------------- ' •--------------•---------------•--------------------------------- ---------------------- --------•---------------------------••-------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------••:------------- ------------------------------------------------------------- ------------- l I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State ws, and ruled regulations of 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). FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY_ -- ----------------------- DATE---1 - --�-Z-Y -- ---- ----- -- - =-------------------------------------- - - -------------------- REVIEWED BY ---------------- --------------------------------------------- ------------------------------------------ DATE BUILDING PERMIT ISSUED--------------- ----- ------ DATE ------------------------------------------------------------ -Alterations and/or recommendafions_----------------------- . FINAL INSPECTION BY: Date-- -- ." --------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED a-59 3M 3-'S3 F.P.CD.