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FOR OFFICE USE: r��= --------------------✓tom- `' ----------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. -------------- -----------4-�__ -D---------- (Complete in Duplicate)p This Permit Expires 1 Year From Date Issued t f 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 Ordi ncW Un549. JOBADDRESS A�yNyD� LOC TION_�� -------�-- --- ----------------------------------------------------------------------------------------------------------- Owner's Name...1 k-- - `d - - ------------------------------------------- Address - - Phone--------------- -•---•---------- Address-------Contractor's Name --------------------------------- Phone-------•--------------------------- Installation will serve: Residence [!�' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ - Number of living units: ---/--- Number of bedrooms___ Number of baths __t____ Lot size ------.--n'� - �? ----•••------------------------------- 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 [!j'FHA/VA: Yes ❑ No In-- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Seprtnt �� j Distance from nearest well________________Distance from foundation--___-____ ____-_-.Material No. of compartments-------------------------Size---------------_----- ---------Liquid depth------------------------- Capacity----------------------- r Dispos- Distance from nearest well.-- .______._Distance from foundation_«______________Distance to nearest lot line._ _______. ❑ Number of lines----(___-__- -.________._--_-Length of each line_6(r___-__-__-.______---Width of trench__,,_++'2__�_._'_______._____-- Type of filter material ___-___Depth of filter material----/_g'_-`____--Total length_______fa_G'_.___-_________________-_ Seepage Pit: Distance to nearest well------------- --------Distance from foundation-------------------.Distance to nearest lot line-----------___ ❑ Number -f-pits---------------------Lining material---------------------Size: Diameter-----------------------Depth--------------------------------- 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_______________-______-____----___. ❑ Distance to nearest lot line--------------------------- -------- ------------------------------------------------------ Remodeling and/or repairing (describe):-----.------------------------------------------------------------------- r --------------------- ---------------------------------- --------------------------------------------------------------------------------------------------•------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County S ordinances, State laws, end rules and r gu ations of the San Joaquin Local Health District. (Signed)-------------------- --`-----=-- ---------------------------------------------(Owner and/or Contractor) BY:---------------------------------------------------------- - Title - ------------------------------------------------------------- -- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). F R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_____.-___ _ ____ - DATE REVIEWED BY - 6 ------- DATE - --- ---------•------------------------------------------------ BUILDING PERMIT ISSUED ------------- ----------------_. DATE----------------------- - -------------------------------------------------- Alterations and/or recommendations:------_--------------- ---_----------------- -------------------- ------------ -------------"----------------------------------------- ---•-----------•---- -----------•----------------------------------------- -------------------- ------•------------ ------•-------------------------------------------------------- ------------------------------------ ----------- ---------------------------------- ------------------ -------------- --------------------------------------- ------------------- ---- ----------------- ------ f FINAL INSPECTION BY:.----- - ---------------------- Date------23` A AOAQUIN 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.C E3.