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FOR-OFFICE-USE. -' ------ ------- -----------" --------- ----- ------- APPLICATION FOR SANITATION PERMIT Permit No: .._ " (Complete in Duplicate) Date Issued ------ -- -----" ------ --------- This Permit Ex ires 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. i This application is made in compliance with County Ordinance No. 549. -- ----"/ __ JOB ADDRESS AN,D�} LOCA.TIION_/-/W-----f r' -------A'`R'`_�-,�� 6-� 1� �� d/ Name W L_- "�C11�--=------------------------------------------------------------------- Phone-_ '�:7-3 o.b- - Owner s t ®o - w: �---------- --------------------------------------------------------- Address / ------------ ---- Contractors Name --- .- Motel Other ❑ Installation will serve: :Residence Apartment ouse ❑ Commercial ❑ Trailer Court .❑ ❑ Number of living units: -------- Number of bedrooms ___-__.Number of baths -------- Lot size ----------------------------- Water Supply: Public system ❑ Community system ❑ Private O''Depth to Water Table -------y Adobe ft' Hardpan ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel El Sandy Loam ElClay Loam Clay ❑ ❑ Previous Application Made: (If yes,date----------- _-- "---) No E] New Construction: Yes [INo j] FHA/VA: Yes ❑ No El TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 264 feet.] . Septic Tank: Distance from nearest wail-----------------Distance from foundation-------------------- Material-______-------------------------- ❑ No. of compartments_.. ----Size-------------------------- --Liquid depth-------------------------Capacity---------- w". well-------- --------Distance from foundation--------------------- Distance to nearest lot Br .. ie_______-.____ -- Disposal Field: Distance from nearest hrh: ❑ Number of lines- --------Length of each line----------------- ---------- Width of trench l Depth of filter material-----------------------Total length------------------------------ ------ Type of filter material------ p ------- Seepage Pit: Distance to nearest ell___ ---------Distance from foundation__1----- ;.Distance to nearest lot line____ _________ Number of pits------- ---"-_ --Lining material---1-o- - Size: Diameter_ - Depth---_- -------- Cesspool: Distance from nearest-well-.--___---______Distance from foundation___- -_.__-___._..Lining material________________ "._'_______-__ \ Liqui Capacity gals. ❑ Size:-Diameter------- ---- --------- -"--- -"- Depth--------------------------------- -"------ ----- q p Y "-----"------------------- Privy: Distance from nearest well __--_.------------------ -----------"-"-"------Distance from nearest building_-_-____-___"___-"---------------------- ❑ Distance to nearest_lot line---------- - --------- - -----------------------------------'- ----- - -------------------------------" ------------- - - - Remodeling and/or repairing (describe :...--------------------------------------------------------------------------------------- hereby fave epprepared this li the San Joaquin Local Health illbDistrict. --cco -- - -- Sa --- - - --- 1 hereb certify that I have re ared +his application and that the work will be lane to accordance with San Joaquin County ordinances, State laws, and rule and regulate q (Owner and/or Contractor) _ (Signe - 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 ACCEPTE�BY_ - . - --- ------ -- ---------- ------------------ DATE----- -`-�S�� ------------- ----------------- REVIEWED ---------"- -- REVIEWEDBY-------------------------------- ----------"_-------------------------------------- ----------------------------------- DATE----------------------- -------------=---------------- ----- BUILDING PERMIT ISSUED--------------------------------- --- ----- - - •---------------------------------------- DATE------------------------------------------- ---=---------- Alterations and/or recommendations:----------------------------------------------- -----" s° -------- ---------------- ------------------ ---- ---------------- ---------------- --------------- ------------------ ir r( FINAL INSPECTION BY - Date "-----7 _7 r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street . 124 Sycamore Street 205 West 9th Street Lodi,California Manteca,California / Tracy,California Stockton,California F.P.C O. t: