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FOR OFFICE USE: --------- ------------------------------------- ------------------- APPLICATION FOR SANITATION PERMIT Permit No. __ - ..:....f ------------------------- - - -- - -- - (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. Thisapplication is made in compliance with County Ordinance No. 549. �� : �1 -7 -Z��O ADDRESS AND CATION-,� '-r�(st< t�'-' -* �' --------_`"------`�' ---------------------------- JOB 'f Owner's Name- . Phone. ----------- Address---- ---------Address----- a� ---- ------------- ----------------------------------------------•---------- •----------. ------------ e Contractor's Name----- Phone----------------------------------- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ F Number of living units: __f-___ Number of bedrooms�- Number f baths _l---- Lot size .__- --c�-#',.�.�-------------------- I Water Supply: Public system C] Community system F] Private Depth t Water Table -------- ft. 9 e Character of soil to a depth of 3 feet: Sand E] Gravel'❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑. Previous Application Made: {If yes,date--------------------I No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFIC7ATl-O'NS: (No septic tank or cesspool permitted if public sewer is available within'200 feet.) Septic ank: Distance from nearest welw 4__-___Distance from�foundafion____•/.C1__.._-_Material __.. -�'.- ------ --.----- -- X � X Liquid depth------ 4--------------Capacity. . -------- No. uo No. of compartments------------------- - --Size__ ----- i Dispo Field: Distance from neat•esf--well:LL'"`------_'Distance from foundation_.__4.C_--_.`_.Distance to nearest lot line_________________ Number of lines_____ ___ ____-_Length of each Iine_SQ_ �'-- �'----.Width of trench.__ ------ Type of filter material--------Skt--------Depth of filter material-----1--9----------.Total length.._/��✓------------------------------ Seepage Pit: Distance to nearest well-------_--------------Distance from foundation-----------._____-.Distance to nearest lot line----- _____-.. ❑ Number of pits-__---------------Lining material_.----------------- Size: Diameter-------------- --- ----Depth------ -------------------------- s 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):.------. rs ---- ' �r, ----•----------•---------- ---- ----------------------------------------------------------------- --------- -------------------I---------------------------------------------------------------------------------------------------------------- ---------------------------r---------------------------------------------------------------------------------------------•--•-------•-------------------------- ------------ ----------- ------------ -- ---------------------------------------------------------------------------------------------------•-------------------------------------------------------------- I I hereby cerci at I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat aw , and rules and ulations of the San Joaquin Local Health District. ( g } _ T nd/or Contractor — e • ---- ------ -- --- ----------------------------------------------- (Title)---------- -------------------------- - ----- -- k plan, sh �iz --- (Plotot, location of system i relation to wells, buildings, etc., can be placed on reverse side). j FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ._ _. ._ -- + r -- --- ------ -----�------- ---- ----------------------- - DATE-- �-�-- ----- - ---- --------------------- -- -- -- ---------- REVIEWEDBY------------------------ ------ -•-------------------- DATE------------------------------------------ ----------------- BUILDINGPERMIT ISSUED-----------------------------------------------------------------------•---------- DATE Alterations and/or recommendations---------------- ----------------------- ------------- - --•------------------------------------•-•------------------------------------------------------------- - - I --------------------------- ------------ ----------- -------------------------------- ----------------------- ------------------------------------------------ -------------------------------------- ---------------------- ----------------------------------------•-------•---------------------------------------------- - ---------- ' FINAL INSPECTION BY:. r. ¢ '�" .t"°� --------------- --"------------------ �r.r, / bate--------.-- ,. SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E.Ho:elton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California