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FOR OFFICE USE: --------------------------------------------------------- -------------------------------------- ----------------- 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 work herein described. This application is made in compliance with County Ordinance No. 549. V--?0_0 •-�° 0.?0--f0 ' f JOB ADDRESS AND LOCATION ------- .j--- - _ _ ----- - ` Owner's Name d /� t ---------------- Phone------------------------------------ Address.........4�_-- (/ "T [y Contractor's Name..(O.i�-r •-. .-- �?.v�� -------------------•---•---• ------- ------ Phone----------------------------------- Installation will serve! Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ ___ Number of bedroom--__ Number f baths 7�Lot size ___. ------ Water Supply: Public system El Community system ❑ Private Depth t Water Table -------- ft_ Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam Clay Loam [] Clay ❑ Adobe ❑ Hardpan ❑ Q Previous Application Made: (if yes,date____________________) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: .r _,i (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material_-__________-_______--___-_____------__-____- ❑ No. of compartments-------------------- - --Size----------------------------=--_Liquid depth----------------- --------Capacity------- ---- '------- Dispos Field: Distance from nearest tell....S_o-------Distance from foundation.---I-b----___._.Distance to nearest lot line__.--&_ _____ �, J. Number of lines---------------------------------_--Length of each line------ V_!...............Width oftrench---�------.--•------------------ I Type of filter material------ of filter material_._�L-4_...........Total length--- • Seepage Pit: Distance to nearest well-=w..,„_�_._-___._ Distance'from foundafiori_-_- °`---`-'Distance to nearest lot line,- 1:1 iner❑ Number of pits----------------------Lining material-----------............Size: Diameter------------------_----Depth--------------------------------- 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------------------------------------------\ ❑ Distance to nearest lot line------------------ ------------- -----'- ---------------------------------------------------------- Remodelingand/or repairing (describe: ------`------ ------------- ------------------------------ -----------------------------•--••---------------------------•- - N ----------------------------------------------------- f f . ---------------------------------------------------------------------------•------ f I hereby certify that I have prepared this application end'fhat the-work will'�be done in accordance with San Joaquin County ordinances, State laws, and rules and eg tions of the San Joaquin Local Health District. } (Signed)---------- --- ---- ----------------- �.. rter and/or Contractor) kBy:----- j -----------------------------------------------------(Title)- ----'- ---- ------------ I (Plot plan, showing size of lot, location of sys m in r ation to wells, buildings, etc., cabe placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- --- - --------- ---------------------------------------- DATE--- Ti� ' (�.--- REVIEWEDBY--------------------------------------------------------------------- - - --------------------------- DATE--------------------------------------------------------- BUILDING PERMIT ISSUED------------------------------ - -- ---- - ---------• -•---------------------------------------- DATE------ ---------- ----------- Alterations and/or recommendations:-------------------- --------------------------------------------------------------------------------------------- ---------------------------- -------•-------------------------------- ---------------------------- -------------------------------------- ------------------------------------------------------------------------------------------------••------------- ------------ -- --- -------------------------------------------------- - ----- -------- -----------------------------------------------------•---------------------------------------- -------------------------------- r FINAL INSPECTION BY:- �s_L. ------------------ Date ---------------------------------- ----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.R Ca.