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OR OFFICE USE: -3- -b�------------------��`� S'3 j - / ---__--- APPLICATION FOR SANITATION PERMIT' Permit o. ._�11. ..... (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. This application is made in compliance with County Ordinance No. 549. JOBADDRESS AND LOCATION----- ---' -„ d ------------------------------------------------------------------------- Owner's Name----------- �t--------- - - ---------------•------------------- ----------------- ------------- -------- 0— ---- Phone_/ _3 31 G Y Ole Address-----•-_------�'�---�--------- � ------� �--------✓��'""''a�`�"'`rz------------------------------------ Contractor's Name-------- >- ------------- Phone..--'--------------_------- Installation --� Installation will serve: Residence [k Apartment House ❑ Commercial ❑ Trailer Court ❑ MotelOther ❑ Number of living units: __ -- Number of bedrooms _-a- Number of baths ---/-- Lot size ____-�-��_._��__`_______________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe, ' Hardpan ❑ Previous Application Made: (If yes,date-------.------------) No JX New Construction: Yes ❑ NoX 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_________________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______._..-__._-. ❑ Number of lines-----------------------------------Length of each line------------------------------Width of french------------- _-_____._.-._____.._ \n Type of filter material----------- Depth of filter material----------------------- length________________________-___-___________ V► r Seepage Pit: Distance to nearest well-_ ._--Distance fr m fo ndation---/d__ __-_.Distance to nearest lot line----g---___.__ Number of pits--------/._.__-Lining material-_ --_Size: Diameter__-s _'� --..Depth----. ,5"`__---- _____. Cesspool: Distance from nearest well-----------------Distance from foundation------.-------------Lining material--------------------------._________- 1 ❑ Size: Diameter--------------------- -------- -------Depth------- --------------------------------------------Liquid Capacity----------------------------gals. Lw Privy: Distance from nearest well-----------------------------------------------..Distance from nearest building_-----_--_--__._____-_----__--_--_. ❑ Distance to nearest lot line----------------------------------------------------------------------._------------------------------------------------------------------ Remodelingand/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. (Signed)-------------------------------------------------- ----- - ------------------- (Owner and/or Contractor By:--------------(:: -----� _...-----------------•---------------------------(Title) - - - - (Plot plan, showing size of lot, location Qfisyssfem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- ------------------ ---------------------- ------ DATE--- --------------------------- REVIEWEDBY------------------------- ------------------------------------------------------------------------------------------- ----- DATE----- ----------------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------- ----- DATE------------------------------------------------------------- Alterationsand/or recommendations-------------------------------------------- ------------------------------------------------ ----------------------------------------------------------------- �� .� ------------ ------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------- -----------------....... ------------------------- -------- -- ------ ------------------------ --- -------------- --------------------------------------------- ----------------- ------------- ---------------------- ----------------- FINAL INSPECTION BY: - ------------------ ------------- Date_....--�.<-_f®.'�� ----------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California h Manteca,California Tracy,California F.P.C C. t