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FOR OFFICE USE: --------------------------------------------------------- / APPLICATION FOR SANITATION PERMIT Permit No. ---------------- --- (Complete in Duplicate) -- --- ------ -- -- -��- Date Issued ___________________________________________________ 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 Ordinance No. 549. 14-VJOB ADDRESS AND LOCATION ---3 ,;11A Owner's Name.....04.......� -- Phone----•----------------•----•-------•- Address. ------------------------ ------------- ................... • .......... 01Contractor's Name C.."_ ------------- ........ Phon1�--.. �X .. -- -- ----------- ------- --- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ElNumber of living units: _ __ Number of bedrooms __ Number of baths J... Lot size ... / ------------------------- Water Supply: Public system ❑ Community system ❑ Private R?-*`bepth to Water Table fA- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan 93-'— Previous Application Made: (If yes,date___-----------------) No ErlNew Construction: Yes ❑ No De FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) nk: Distance from nearest well_________________Distance from foundation--------------------Material_______________.____-_._____----_____._____-____. No. of compartments-------------------------Size-------_-------------------•-Liquid depth---•----------------------Capacity........................r -- line. ,,II Disposal Field: .Distance from nearest welL.�C__._�Distance from foundation...�_�_.____-_-Distance to nearest lot �•._1! Number of lines___..__._.__ ___._ Length of each line----�?�...�.1...__��__.Width of trench.._. ,$�___"________________ Type of filter material..__% 4s-/_('._Depth of filter matenaL.-----1B-------Total length..... hS:________________________•.__ . Seepage Pit: Distance to nearest well _r------Distance fr foundation---s _......Dist Distance to nearest lot line--- ?n- Number of pits_.__-_/._________Lining material__._ -C-e---.Size: Diameter_�.�._.____.____Depth____-9_,�__-______.___-___ Cesspool: Distance from nearest well----------------- from foundation._______..___-_._.Lining material___-__-_._.-_________.__.__________--. ❑ 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 r ulations of the San Joaquin Local Health District. (Signed)------ ------------------------------------- - --e-- -- -----( ' nor and/or Contractor) By:•-•••-•-------•--•-•-•--------•-- ------------------ ----- --•-•-(Title)_.. ._ - --- -------- --- - ------------ (Plot plan, showing size of lot, location of system in ation to wells, buildings, etc., can be pl ced on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- -- ----- -- - - Y'` --------------------------------------------- DATE./:n/!'--__o--------_--_--.-------------------- REVIEWEDBY------------------------------------ -------- •---------------------------- DATE-=------=--------•----------------------------------------- BUILDING PERMIT ISSUED.----------------------------------------------------------------------------------------------------- DATE.-'-} --------------------------------------------------------- Alterations and/or recommendations----------------------------------------------- -------------------------------------------------------------------------------------------------------------- ------------- -------------------------------------------------- -------------------- ----------------------------------------------------------------------------------------------•------------------------------------- ---------- -------------- --------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------•-•---------•----------- -----------------------------------------------------------------------------------------------------•-------•-------------------------------------------- ------------ --------------- ------------------ --------------------------------------------------- ------------------------- ---------------------------- --------------------- --------------- ------• ------------- --- � r FINAL INSPECTION BY _--=�'----_------ ---------- Date__.._ _` -- 1 ---------------------------------------------- SAN - ---- --- - ------ --------------------- 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