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FOR OFFICE USE: -------------------------------------------- -------------_------ _ _ __'__} : __._ -------------- APPLICATION FOR SANITATION PERMIT Permit No. cc �J --------- 1--------- --------------- ---------------- (Complete in Duplicate) ---------------------- This Permit Expires 1 Year From Date Issued Date Issuedf_-�� 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. JOB ADDRESS AND LOCATIO _____ Owner's Name__------� -•--••-----•---_---------- --•---- ------------------------ -------------- Phone.................................... Address................ --------------------/ Contractor's Name-----.---- -- ---------- - -- --------- ---_ -- - ------ Phone__'"�_'_/_•GLt... �T._L Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Other El Number of living units: ___/_ Number of bedrooms __'Q___ Number of baths __ Lot size _.-_______________ Water Supply: Public system ❑ Community system ❑ Private [9,,"bepth to Water Table 7_`. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date____________________) No [New Construction: Yes ❑ 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_ = �_. Distanc� from foundation_-/a.�____ Material---_'�- •--- - /J ©� No. of compartments----a--_--____�___Size�j__.7e1_X(� -.'Liquid depth-------f -.____.________Capacity_/._? J ---- Disposal --Disposal Field: Distance from nearest well-^ -------Distance from foundation...pl4_-.� Distance to nearest lot lire: -- [ Number of lines____________ Length of each -------Width of trench-__49 _____________________ Type of filter material_. Q�_A----Depth of filter material___ -- -- - _ Total len th----------------------��-4.----- Seepag Pit: Distance to nearest well_144 + Distance m fo ndationQ_-------Distan;p to nearest lot line _�� Number of pits------ --_--_-__--Lin ing material-` _-Size: Diameter___' 3--- - - ----Depth-----.�5---------------- 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---------------------------- __._..__-- W ❑ Distance to nearest lot line------------ ------------------------------------------------------------------- Remodeling and/or repairing (describe):___ "pi __ _-e �1- -------- ------------------•------------------------------------------------------------------------------------•------•- ----•------------------------------------------------ - ---------------------------------------------•------- ------------------------------------------------------- - -------------------------------------------------------------•--- -------------------------------------------------------------------------------------------------------------------------------------------- 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 gulations of the an Joaquin Local Health District. (Signed) C/r (O er and/or Contractor) By:--- ---------------------------------- -- -- -- ----- -- -----------------(Title)- ' - (Plot plan, showing size of lot, location of system in relation t wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED - `� _ �_�� y% DATE----- � "7 . ---- --------------------------------------- REVIEWEDBY----------------------------------------------- ---- ---------------------------------------- -------•- DATE --------------- UILDING PERMIT ISSUED----------------------------------------------------- ---------------------------------------------- DATE----------------------- --------- A terations and/or recommendations:------------------------------------------------------------------ ----------------------------- ..__. ----- --------------------------------------------------- ----------------------------• -------------- ----------------•------------------- ------------------------------------------------------- ---- --------- -------------------------------------------------------------------------------------- --------------------------------- ------------------------- ----------------------------- -------------------------------------------------------------------- �— FINAL INSPECTION BY: ... �1, -«cc 7 Date------ T-"Z-�__- -- --- ----------------------- --------- 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.P.CO.