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FOR OFFICE USE: S=a- ----- ------ --- --- -- /�� g ---------------,_---------•,---------_-_ .:.�__-_ APPLICATION FOR SANITATION PERMIT Permit No . t {Complete in Duplicate) - -------------------------------------------------------- A -- -----•----------- --- � 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, JOB ADDRESS AND LOCATION---- ---------J-7---` ` '------ 1!_`Y-------------- ---------------- = Owner's Name------------------ ----- Phone._.-.--------------------•-•-------- Address-------------------------/7-G1-1--- �%•cp-----------------------------------•-- { Contractor's Name_____________________ / } Phone._. _ 0 Installation will serve: Residence ❑partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __L___ Number of bedrooms _ _ Number of baths j____ Lot size ---.----------------- aag _________________ Water Supply: Public system 2___C&mmunity system ❑ Private ❑ Depth to Water Table " ft. Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ ,Sandy Loam [] Clay Loam ❑ Clay 0 Adobe 0 Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ No B FHA/VA: Yes ❑ No B 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.-_---.------.---_..-_-___-____---__....__---. ' 1No. of compartments------- ------------------Size--+- ----------------- ------Liquid depth------ - ----:Capacity-- ---' Disposal Field: Distance from nearest est well_______________`_Distance from foundation--------------------Distance to nearest lot line________.___..... Number of lines.---------------------------------Length of each line------------------------------Width of trench-- ---------.----------------_-_ Type of filter material_______________________Depth•.of filter material----.------------------Total Seepage Pit: Distance to nearest well--7�----._--Distance from foundation----&?L—-------- Distance to nearest lot line----A S [ � Number of pits-_-!._- - -----Lining materiaLS_0 -[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 (describ`e]:---------------------=`------------- ----------------------------------------------------------- -------------------------------•--------------------•-=- el ---------------------------------------------------------:------------------------------- ------------------------------------------------- _ __ 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 laws, and rules and regula+ions of +he San Joaquin Local Health District. (Signed) �___.__ ___ Owner and/or Contractor rl By------------------------------------------------- -----------(Title)-------� - --------- f (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--------------Z ---------- --------------------------------------- REVIEWED BY ----------------------- - . DATE BUILDINGPERMIT ISSUED--------------------------------------------- ------------------------------------------------------ DATE----------- --------------------------- --------------------- Alterations and/or recommendations:_-}--------------- ------------------------}--- -------------------------------- --•-----------•-•-----------------------------•-------- ------------------ '� -------- t .x i3 FINALINSPECTION BY: ------'`--- `-------------------------------------- Date. ---------------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracyr California F.P.CG- v f