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FOR OFFICE USE: la-i -�-r ---- /0 I -- ---------------- --------- APPLICATION FOR SANITATION PERMIT Permit No. .._......_......� ------------------------- ------ -- ------------ (Complete in Duplicate) Date Issued A?_�/,�/-_.__.��_ --------------------____-_____.__--_______----------- I 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. JOBADDRESS AND LOCATION.--- -------------------------------------------------------------------------------------- Owner's Name--- ---------------------------------------------------------------------------------------------------------------------------------------------------------------- ------- Phone------------------------------------ Address----------------�-'+F� Contractor's Name `------- ------------------- Phone------............................ Installation will serve: Residence [!T 11 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __.j--- Number of bedrooms .__2. Number of baths ---t--- Lot size ------77X_,�� ____----------------------- Water Supply: Public system a-tommunity system ❑ Private ❑ Depth to Water Table 40 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Ej- Hardpan ❑ Previous Application Made: (If yes,date- _______ ) No [9"" New Construction: Yes ❑ No [ FHA/VA: Yes ❑ No f '' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) SepticnL Distance from nearest well-----------------Distance from foundation--------------------Material ----------------------------------------------- ❑ ' No. of compartments---- -------------------Size------------------------------Liquid depth----------------------- Capacity---------------------- Disposal Fielo:y Distance from nearest well__—.____.-_Distance from foundation._Aa_--- .. -.-__. Distance to nearest lot line._.�..... ❑ Cr Number of lines_....I'----------- -----------------Length of each line----7_la.'_----------------Width of trench-----A�_' _--_-_.-.-__--_---.- Type of filter material_- 06_,f_____-_Depth of filter material----Ir------------Total length-------74!_`_________________________ (J Seepage Pit: Distance to nearest well----- ----------------Distance from foundation--------------------Distance to nearest lot line--.--.----------- El Number of pits--- ------------- _-Lining material-_--_ __ ----------- Size: Diameter------.------- ----.---Depth_________________-_............. Cesspool: Distance from nearest well.---------.------Distance from foundation-----------------_Lining material-------------------------------....... Q ❑ 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---------------------------------------------------------------------------------------------- ----------------------------•--------------------------- ------------------------- ----- ----- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I ----------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I-have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State Iw- and rules an regul tions 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). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- = ------- --------------------------------------------------------- DATE------ -J----------------------- REVIEWEDBY--------------------------------------------.------------------------------------------------------------------------ -----_ DATE------------------------------------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE--------- ---------------------------------------------- Alterations and/or recommendations------------------------------------- ------- ---------------------------------------------------------------------------------------------------------------- ------------------------- ------------- ------------------------------------ -------- -------------------------------------------------------------•------------------------------------------------------------------------- ------------------------------------------------- ------------ ------------ ------ ----------- -------------------------------------------------.------------------------------------------------------------ -----------------------...... ---- -------- ---- ---------------- ------------------------------------------------------------------------ ------------------ --------------------------- ----------------- --------------------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:----- . -- .------- ---- ------ - Date------- Y=6J /------ -------------------- --------- 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.C C.