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FOR OFFICEUSE.. -� APPLICATION FOR SANITATION PERMIT Permit No. ../...�7 --------------------------------------------------------- �o/ ;f-�- (Complete in Duplicate) Date Issued --------------------------------------------------_-.-_. This Permit Expires 1 Year From Date Issued I P 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 OCATION__ --_- ------_ -L -4___-_____ _ ��67 - -- ------------------------------------------------------------------------------•------------ Owner's Name----- --= - -- Phone----------------------------------- Address �° . ------------- -----------------------------•-------------------------------------•------�-``-----.----.--------- Contractor's Name--------- ------------------------------------------------------------------------ Phone//0x �.°._o q Installation will serve: Residence ,' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 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____________________) NojX 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.) 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------------------------------------ Type of filter material----- - --- _____Depth of filter material------------------ Total length____________________________________ __ Seepage Pit: Distance to nearest well__ ___Distance f m undation-----,��-------Dist nce to nearest lot line-____--5.-_ Number of pits-----_---! ____ ___Lining material---Z4 ____Size: Diameter____-3$.. p f 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 hne-------------------------------------------------------------------------------------------------------------------------- ----------- Remodeling and/or repairing (describe):-------------- ----- --------------------------------------------------------------•-------------------------------•------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ t , �- ------------------------------------------------------------------------------------------------------------------------------------------------------------•--------------•---------------------------------•-- -- --- ---- 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 nd/or Contractor) BY� ` - " c. _- ---------- -----------------------------------(Ti+le) - -------------------- - ---- --------- (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 !49---- ---` ------------------------- REVIEWEDBY------------------------------------------------------------------ ----------------------------------------------------------- DATE--------------------------------•--------------------------- BUILDINGPERMIT ISSUED-------------- -------------------------------------------------------------------------------------- DATE--------------------- -------------------------------------- Alterations and/or recommen ati ns______________--___-____ � ---------- --------------------------------------------------------------------------------------------------------------------------- -----------------------I--------------------------------------------- -------------------•-- --- ------------------------------------------- --------------------------------------I--------------- -------------------------------------- ---- ------------------------------------------------------ ------------ --------------- -------------- --------- ----------- -------- ---- ---- ------- -- ---------- -------------- FINAL INSPECTION BY:----- - - C%� /Q;&-- J - /--------------------------------------------- Date ------- ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselion Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.00.