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FOR OFFICE USE: --------------------- - ----------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .� __1 11 (Complete in Duplicate) Date Issued _------- I This Permit Expires 1 Year From 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 Ordinan a No. 549. 0� �Q • Y JOB ADDRESS^D LO AT N /-- --4044t Owner's Nam --------- --•----- --- - -•-----•--•---- ---------------------------- Phone-----•---•------•------•--•------.-. Address "..�....... ............• --• --•-••....... •. Contractor's Name............... •-- -••••-• --- - - ---- Phone ---------------- Installation will serve: Residence ❑ Apartment ouse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/--- Number of bedrooms _yNumber of baths ---/_. Lot size ....... --------------------------- Water -.._--------------- 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---__------_____----) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) P Of Septic nk: Distance from nearest well--.-. Distance from fo-undatip n.-.--- ............Material--.----.-dlo_ ---.-..... No. of compartments----------?�.___--Size.Y..6-__ .X- Liquid depth..........---_------------Capacity..... Cs .G.�._ Dispos Field: Distance from nearest well_- jQ-i-_,Distance from foundation.-l4.�----....Distance to nearest lot line.... -. ... Number of lines............./--------_---- ---Length of each,line------------/_pa ....Width of french------t-. .-.--------.-----.-.- Type of filter material---------- �JL---Depth of filter material.....(_Q............Total length---.--- ----------------------- Seeps Pit: Distance to nearest well-----/�_U./...._Distance fro foundation---/�..........Distance to nearest lot line-.s e........ 71 Number of its....--_ Linin material.. Diameter __._.---.Depth._-P�.+�.�................ p' �__...----- g Cesspool: Distance from nearest well------------------Distance froin foundation--------------------Lining material-------------------------------------- 0 Size: Diameter--------------------------------------Depth-------------------•--=------------ --------------..Liquid Capacity----------------------------gals. Privy: Distance from nearest well...........................................:..:..Distance from nearest building------------------------------------._._.. ❑ Distance to nearest lot line----------------------------------------------------------------------------•-------------•-------------•-------------•-------------------- Remodeling and/or repairing (describe):---------------- ............................................................-.........................................................-------- ------------------------------------------------------- --------------------------------------------------------------'------------------------------------------------------- ------------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 regulations of the San Joaquin Local Health District. (Signed)------------------ --- ------ ------- and/or Contractor) BY: (Title)---------- ------------------------------ ------- ------------- ---------- --- ------- ------ ------------------------------------------- (Plot plan, showing size of lot, location of system in rela on +o wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-._ -•- �----------- ---------------------------------------- DATE-/-a-----�7--�- --------------------------------- REVIEWEDBY---------------------------------------------•--- --------------- ------ DATE---------- -------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------•--------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:-------------------------- --------------------------------....................-------------------------------------------------------------------------------- -----------------------------------------------------•----- --- ----------------------------------------------------------------------.....................................---------............................. ---------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------- •--------------------------------------------•---------------------------------------------------------- ------------------------------•----- ------------- -------------------------------------------------------------- ----------------------------------- ---------------------- --------------------------------------------------------------------------------.------------------------- -------------------------...-------- FINAL INSPECTION BY:.-el ---- ------ Date- ----------------------------------- 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