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FOR OFFICE USE: -------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. -- _--- --____-- (Complete in Duplicate) Date Issued ---.--- _ This Permit Ex ices 1 Year From Date Issuedr 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. n -m1q- JOB ADDRESS AND LOCATION �--------�J---------------------------- Owner's of '_..:1t 1 `. Owner's Name-_vv.jj_ ,t-,qlY -p_k/g1 - Phone _� ,� Address ------ -6-2-S7-------- ��[ f1_ _�rt Contractor's Name----- , E.r. ._ _ 9� 0 ;� - � --- -�•;�--�-�'/- ---�'�`-�------------------------------- •-- -------------------------------------------- Phone--- ---�s�........... Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size ------ 4ate.1.0_of"_��- ----------_______ Water Supply: Public system ❑ Community system ❑ Private R Depth to Water Table/0- ft. Character of soil to a depth of 3 feet: Sand V Gravel ❑ Sandy Loam [❑ Clay Loam ❑ Clay [] Adobe ❑ Hardpan EP Previous Application Made: (If yes,date..------------------) No X New Construction: Yes ❑ No M FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r Septic Tank: Distance from nearest well_________________Distance from foundation--------.----------Material----------.-------__---_.._--_---______-_-._- ❑ No. of compartments--------------------- ----Size--------------------------------Liquid depth.--------- --------------Capacity-------------- -------- Disposal Field: Distance from nearest well----.t` ..__Distance from foundation__f-C'----------Distance to nearest lot line----J_-_------- Number of lines--------------- _____________Length of each line------ --------------Width of french-------�.----------------------- ._ _ Type of filter material---��4v_ k------Depth of filter material----._r_�!____.__._Total length-------76.--------------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- F] Number of 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)-------- --------------------------------------------------------------------------------------- -------------------------- ---------•------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- -------------- 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. - r (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). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------)---I-R--4-Q----------------------------- ---------------------------------------- DATE-------- 1 f� ' t--------------- REVIEWEDBY --------------------- ----------------- - ------------------------------------- DATE---------- ------------------------------- BUILDINGPERMIT ISSUED----------------- ---------------------------------------------------------------------------------- DATE----- ------------------------------------ -- Alterations and/or recommendations:------ ------ ---- --------------------------- -----------------------------------------------------------------------------•---- --- - - ------------- ------ - --- ---- -- --------------------------------------------------- - - ----------------------------- F€NAL INSP Y 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 F.P.CO.