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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. JOB ADDRESS AND LOCATION------- © --------------------------------- Owner's Name----------- Q-........k-'...... ----•---------------------------------------------------------------- Phone..................................... - Address.............. - ------ ------------------------------------•-------------------------------------- Contractor's Name------- t -•CD- � r - --------- � ' ----....... ------- Phone----------------------------------- Installation will serve: Residence X Apartment House ❑ Commercial `[] Trailer Court ❑ Motel EJ—other ❑ Number of living units: ----1--- Number of bedrooms ___(____ Number of baths ---I---- Lot size ____S ._.__ __l..Q_!?________________________ Water Supply: Public system 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: (If yes,date_--_---------------) Noj% New Construction: Yes 1W No E] FHA/VA: Yes E] 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_4 _hk _0E_Distance from foundation____:1-0.�_______.MateJrial___-C—OX—Q ��-�-�'_____________ No. of compartments----------- ----------.-----Size---- __.Liquid depth--- --z..----------Capacity---OPa__- _.-___ Disposal Field: Distance from nearest well_NO-NCDistance from foundation------10........Distance to nearest lot line-----�.1=__-___-Number of lines-----------1--------- -----------Length of each line_______k-Q_'_------------Width of trench-------- --------------- Type of filter mate ria -_ S•- Depth of filter material length___________________ n __-- ---------- Seepage Pit: Distance to nearest well_ _ _______________Distance from foundation--------------------Distance to nearest lot line_____-------___-_ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter--------------- -------Dept h_.-.-____----__--____---____ Cesspool: Distance from nearest well--------------___Distance from foundation -____._-.Lining material---.---_--___--_--______-___________-. 1 ❑ Size: Diameter-------------------------------------Depth------------- ---------------__-------------------Liquid Capacity-------._-----------•------gals. Privy: Distance from nearest well --_-_--------_------------------------.-------Distance from nearest building------------------------------------------ r_1 Distance to nearest lot line--------------------------- ----------------------------------------------------------------------------------- -------------------------- Remodeling and/or repairing (describe):------��. -'r.F..rst�' '� ---"A --•-•- .........-------- ----------- --------------- --- ------------- -- - -- ---- - -------- -----rye--io - ------- - -- ------- --- - ---------- ----------- - II he�rtify at I 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 the San Joaquin Local Health District. (Signed) - ------------------------ "--------------------- ---------------------------- --------(Owner and/or Contractor) 13 ---- -------- • (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 APPLICATION ACCEPTED BY -- ----- "L------------------ DATE �j - -- REVIEWEDBY--------------------------------------------- - - ------------------------------ RATE•--•--------- ---------------------------•--•--------------- BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- D E------------------------------------------------------------- Alterationsand/or recommendations------------------------------------------- --------------------------------------------�-------------------------`--------------------------------------- - ------------------------------------------------------------------------------------ -------- --------------------------------------- --------------------------------------------------------------•-•---•------------- -------------------------------- ------------------_-Z17 - ------------------------------------ --------- ._-- -��- -------------------------------------------- ------------- ------------ -------------------------------------- ---------------�----- ---------------------------- ---•- FINALINSPECTION BY--------- ------------------------------------------------------- Date---------,----------------------------- ------ ----------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California