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FOR OFFICE USE: APPLICATION FOR SANITAVON PERMIT Permit No. ................. -------------------- ----------------------------------- (Complete in Duplicate) �— ---------------__------.----------------------------- I This Permit Expires 1 Year From Date Issued 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 Ordince No. 549. JOB ADDRESS AND LOCATION--- ------ j�.-- .. ------------------------------ ----------- ------------------------------------------------- Owner's Nam -- 1�? --------------------------------------------------------------------------------- Phone._--------------------------------- Address .. (,,1�------------------------•--•-------------------------------------•-------•-------------------------------------------•---------------------•-------------------•------•----•-------------- Contractor's Name____ ___ ='�- '� Phone Installation will serve: Residence R `Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --I----- Number of bedrooms __2_ Number of baths _1_-__ Lot size ----1�----- -- ------------------------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table 0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ETaerdpan ❑ 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.) Sep4�� Distance from nearest well_________________Distance from foundation--------------------Material-------------------------------------.----------- No. of compartments--------------------------Size-------------------------------Liquid depth------------- ------------Capacity----------------------- Disposal Field: Distance from nearest well-----.--------._Distance from foundation--------------------Distance to nearest lot line----------------- El Number of lines___________________________________Length of each line------------------------------Width of trench------------------------------------ cN Type of filter material------_-------------_----Depth of filter material-----------------------Total length------------------------------------------ ___•— Seepage t: Distance to nearest well ------------Distance f, foundation_ rr ;_6?--- to nearest lot line�` _�____ E Number of pits------/____.________Lining material_`_/ 'ck-Size: Diameter_:-. _3..________Depth___--007.-_.________-_ 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 tW I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State la an les and r la ' ns of a 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-----------4_4! --f REVIEWEDBY-------------------------------- ------ ---------- --------------------------------------------- ----------------------------- DATE---------------------------------------------__----------- BUILDINGPERMIT ISSUED--------- -----------------------------------------------------------------------------------------.- DATE------------------------------------- ----------------------- Alterations and/or rF-co- mmendat-ions : --,tet ---------- ------- ------------------------------�----- ----------�-----l- �' � r �---- � _--_____._ ------------ �---------- -------- - - ----------- -- ------ ------- - FINAL INSPECTION BY:..... - 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.