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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) �� This permit Exiaires 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. JOB ADDRESS AND LOCATION_.___j1_ZG"-.C- -1_u _ ------------------------------- Owner's Name -----_ � !t1,a.._ --- ------------ - ------- Phone_-------------------------- Address------------ Contractor's Name ----- ------ Phone-- ------------------- --------- - --------------------------------------------- --- - Installation will serve: Residence I!T� Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _______ Number of bedrooms ", Number of baths Lot size Ga[ Water Supply: Publics stem j�,�r PP Y� y [Community system ❑ Private ❑ Depth to Water Table /------ ft. Character of soil to�-a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No [J" New.Construction: Yes ff�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--------------- -..._ ❑ No. of compartments -------- - ------ -Size------------------ -------------Liquid depth-------------------- Ca ac-- Capacity --------------- Disposal Field: Distance from nearest well-----------------Distance from foundation---------.---_------Distance to nearest lot line-- ❑ Number of lines-----------------------------------Length of each line------------_------------- Width of trench---------------------- ------------- Ype of filter material-----------------_------Depth of filter material-------------.--------Total length--------------------•--------------------- Seepage Pit: Distance to nearest well.. l t i "V �1bd�----_--Distance from fgundation-_.�11.___________ Distance to nearest lot line__-_____.._ I Number of pifs...._ Lining material77t -Ga--[---. Diameter-,33."... ter`-• .Size: --_-- Depth-----�-- ------------------- esspool: Distance from nearest well-----------------Distance from foundation ._ ----- Lining material___-------._._____.._____.._-------- � ❑ Size: Diameter_._ --------- ---------------------- ---- - -------------Liquid Capacity-L--------------------------gals. Privy: Distance from nearest well___----------------------------___-----------.___Distance from nearest building ❑ Distance to nearest lot line.____________________ Remodelingand/or repairing (describe):-------- - ---- -------- --------------------------------------------------------------------- -------------------------------------------------------- ----------------------------------------- } ----- -------------- ------ ----------------------------------------------------------------------------------------------------------- ---------------------------------------- I hereby certify that I ha pr ared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and r' es dregul ions of the San Joaquin Local Health District. (Signed) --------- ---- -- --- - �.. ----------- -------------- ---- ------- . ---- .(Owner and/or Contractor] By:-------------------------- Tale (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 APPLICATION ACCEPTED BY__.�� - -__ ------- ------------------------------------ DATE �'- REVIEWED BY_---------------------------- ------- ---- -- -------- -------------- - ---------------------- DATE - •-- BUILDING PERMIT ISSUED-------------- ------------------------------------------------ ------ -- ----- ----- -----------------__ - -------- - DATE-- ----------- - -------- -- ------------------------- - terations and/or recommendations:._____..._____. - ---------- 7� - - - ---�----------------- ----------------------------------------------------- -------------- ---- --------- ------------_------------------- - -._---- ----4 -� ---------------- ---------- - -------------- - ----- - ---------------- --------------- --------I----------- FINAL INSPECTION BY:. �' ri -LtJ 't � Date------..._ �tJ.0 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California FS.9 -2r,4