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FOR OFFICE USE: ------------------ ----------------------------- --- /�� ---------------------- - - APPLICATION FOR SANITATION PERMIT Permit No. ........................ ---------------------------- ----- ------------------- ---r---------------------------------- (Complete in Duplicate) G� Date Issued This Permit Expires 1 Year From Date Issued W 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. � r AD' a � = ------------- JOB ADDRESS A . CATION. - -�4- '':'= Owner's Name-- - - •- - ----- ---- Phone Address = � �- ------------------- - ---•-- ----- d ! w Contractor's Name --------- --_------------ ---- � Phone. � Installation will serve: Residence L Apartment House ❑ .Corn emi 0 Trailer Court ❑ Motel ❑ Other ❑ N.mbar of liv ng units: __f.---- Number of bedrooms Number of baths ---- 'Lot size _---__-___ ___... _ __-. __._------------------ Water Supply: Public sys`t�em ❑ Comrrlunty_system fl1,Flrivafe [Depth to Water Table ._____.. ft. Character of soil to a depth of 3 feet: Sand L] Gravel E] Sandy Loam E] Clay Loam [Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: {If yes,date-------------------- No ❑ ew Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: u (No septic tank or cesspool permitted if public seweriS'*available within 200 feet.) Septic Tank: Distance from nearest well----------------- Flom foundation-------------------Material----------------------------------------.___---. ❑ No. of compartments-------------------- -----Size------------------ -------------Liquid depth--------------------- . Capacity--------------- Disposal .Field: Distance from nearest well----S f----Distance from foundation-- .-/Q---------Distance to nearest lot line-.�re--f------_ 1 Er Number of lines---_____l__- -- -----------Length of each line------1_0-Q-_----.._-----.Width of trench.__;?�_--._-__-___----.----._--.- 1 Type of filter material._..--.�+----- ------Depth of filter material----/__4._----------Total length---/P.v----________________________- i ry�3� i Seepage Pit: D+stance to, nearest well--------------____---Distance from foundation-----------------.- Distance to nearest lot line----------------- 14 t ium43ei cr os�.rf{f. i ❑ I�, pits---------------_--_--Lining material-----------------------Size: Diameter--------------------_--Depth--------------------------- ------ .� . Cesspool: IDistance from nearest well-----------------Distance from foundation--------------------Lining material-------- ------------------ ❑ Size: Diameter------- - ----------------------------Depth--------- ------------------------------------------Liquid Capacity------------------------ --gals. D Privy: Distance from nearest well--------------------------------------.----------Distance from nearest building_____--------.-------------__-__.-_-----. ❑ Distance to nearest lot line--- - ----------------------- ---------------.------------------------•------------------------------------------------------ ----------------- Remodeling and/or repairing (describe)__________ ____�__/_ -- -----------•---------------•----------------------------------------------- i{ -----------------------------------------------._•--- ---------- --.----- ------------------------------------------- ---- ` 1l'" --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- �'" - ------------•----------------------------------------------------------------------------------------------------------------------- -------------------------------------- ------------- I hereby certify that 1 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-thezSan-Joaquin-Local-Health — (Signed)--- ------ -- -- --- ------------ --------------------------- -------- ---------------- - --------((S;W. and/or Contractor) By:.... --- ----•- --------------- - --------------------------------------------- -------(Title)------ ------------------------------------ - -------------- (Plot plan, showing size of lot, location of system in re anon to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ------- =---r- ' -~.--=`---- --------------------------------------------- --- DATE_---�?-^f r -------------------------- REVIEWEDBY--------------------------------------------------- ----------------- ------- ----------------------------------------------- DATE----------------------------------------------•------------ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------- ----- DATE---------------------------- ------------------------------- Alterationsand/or recommendations:------ -------------------------------------------------•---------------------------- ------------------------------- ------------------------------------- ---------------- --•------------------------- ---------..-----------•----......---------------------------------- -------------------------------------------------------------------------- --------- =-------------------- ------------------- -- ----------------------------- ------------------------- ---------------------------- FINAL INSPECTION BY: _:_ _.. ....... ----.------- Date--/,Q-.-/ _ .... ---- ----------------------------------------- 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 F.a.c O.