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-1 vi 11\-L- UJL: -------------------------------------------------------- - ----------- --- APPLICATION FOR SANITATION PERMIT Permit No. . _h�l� --------------- (Complete in Duplicate) --- --------------------------------- - ------------- This Permit Expires 1 Year From Date Issued Date Issued ----------------- Application 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 LOCATION______- ------- - -- ------------ ----- Owner's Name------- 4// r/ ---- -- ---- - ------------- - Phone__7 T - 7 � 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 -------- Lot size ________ -------------- Water Supply: Public system E] Community system E] [4 Private ' Depth to Water Table _/®_ ft. Character of soil to a depth of 3 feet: Sand ElGravel E] Sandy Loam E] Clay Loam E] Clay E] Adobe Ej- dpan ❑ 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.) Septic Tank: Distance from nearest well_�Q_-__-Distance from foundation_ -_lD-- - _ . --__-_.Material-__. �twr�C�-� _ No. of compartments-.-__,�__-----------Size_-_ SSC / f �`- -----Liquid depth-------5 t--- -.- Capacity----- ----' - - -•-------- Disposal Field: Distance from nearest well-37 Distance from foundation__li9... _.-__Distance to nearest to i e___ Number of lines_____-_/_--- ____,__Len th of each line__-___ _- 9 e'G`�_..--____-..Width of trench----_.. ------------------------ Type of filter material-_---_- AC __Depth of filter material-- I-GG_-�' a O -Total length------- Seepage ---/3-- ------------------------- Pit: Distance to nearest well-___--___--__--_-Distance from foundation__-_____--_______.Distance to nearest lot line________._____ ❑ Number of Pits------------------ -__Lining material----------__ -__-_Size: Diameter-------------- ------------------ Cesspool: Distance from nearest well-.-____--.----Distance from foundation-------------- _.Lining material__-_-_-._____-________ ------- Privy: _ ❑ Size: Diameter-__ . - --__-_ - - Depth - -----------------------------Liquid Capacity -------------------------gals. Privy: Distance from nearest well___ __ __ Distance from nearest building ---------- -- - ------- ❑ Distance to nearest lot line.- __- Remode'ng and./or repairing (describe):------ - --- J - -------------------------------------------- '`- '""' I- �` 2-- ------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---- -- ------- ------ --- ----- ---- --------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepa ed +his application and that the work will be done in accordance with San Joaquin County ordinances, State Ca�, and rules an re lations of the San Joaquin Local Health District. (Signed) t..� --- --------- ------ - 4_ _ o,l i ------(Owner and/or Contractor By:----- 4 - - - --------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). '0 F R DEPARTMENT USE ONLY 100 APPLICATION ACCEPTED BY_- -. c_e. -------------------------------------------- DATE---- 2 " REVIEWED BY---- ------------------- ------- --- -- .............. -------- --------------- - . . -- --------------------------- DATE BUILDING PERMIT ISSUED-____.-__.-- ---------------------------- ----------------------------- ---------------- ------------------------------ - --------------- DATE--- ---------------------------- Alterations and/or recommenda+ions:__-__-__----_--_--_.-____-_ -- --------- ------------ -------------- -------------------------------------- ------------ ----------- --------------------------------- FINAL INSPECTION BY:--- c- ---------- ----------- - Date-_.' - '- ' - - -------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street Stockton,California Lodi,California 205West th Street Manteca,California TrrWest Callifornia F.P.CO.