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FOR OFFICE USE: j ---------------- ------------------------------------ APPLICATION FOR SANITATION PERMIT Permit No. ... _.-�3•. _.. r --------------------------------------------- (Complete in Duplicate) fd _._...____- T_his Permit Expires i Year From Date issued ____-�j_--�C�,C Date Issued _ ------------------ Application is hereby made to the San Joaquin Local Healfh District for a permit to construct and install the work herein described. This application is made in compliance with CouJnty Ordinance No. 549. JOB ADDRESS )AN LOCATION---- [ . ---- Owner's Name_._ .-- E Phone ------------- Address----------- ------------- ----------- - ------ --------------••------------------------------ ----------------------------- ------------Name 4 •--- ---------- --- Contractor'sf7r-- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ..f--- Number of bedrooms-j.. Number of baths _f-_ Lot size ---------------- Water Supply: Public system V Community system ❑ Private ❑ Depth to Water Table 4VQft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobeg Hardpan ❑ Previous Application Made: Elf yes,date--------------------1 No ❑ New Construction: Yes ❑ Nog FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) P_ e' • Ta,Pk: Distance from nearest well------_--------Distance from foundation--------------------Material---------...---._...-__-______________---_-_. No. of compartments------ -------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- 04_W1;WV Id: Distance from nearest wel lance from foundation-__4_._......Distance to nearest lot line {y Number of iines_-___ .___ _Length of each line_- -1---_Width of trench._._, _ ---f_ Type of filter material-------�Q_C_ _-Depth of filter material.-_/__9-__------Total length---.-------------------- --------------.- Seepage Pit: Distance to nearest well .-----Distance from foundation-------------------Distance to nearest lot line-_._-.---.._----. ❑ Number of pits---------------------Lining material-----------------------Size: Diameter----------------------Depth---._..-------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation...-----------------Lining material--..--------___.____-__---_----.----. J)i ❑ Size: Diameter--------------- -----------Depth---------------------------------- -----------------Liquid Capacity--- -----------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-------------- ------_-..-.--.--_._____� ❑ Distance to nearest lot line----------------------------- ---- ---------------------------------------------------------------------------------------- ---- ------------ Remodelingand/or repairing (describe):---------------------- -------------------------------------- ----------------------------•--•---------------------------------------------------•--• E --------------------------•----------------------------------------------------------------------------------------------------------------------------------------------------------•--------------------------------- ----- 0 ----------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- p ----- ------------------------------------------------------------------------•-------- ---•------------------------------------------------------------------------------ ------------------------------------------------- �+ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, J4afe laws, and rules and regulations of the San Joaquin Local Health District. a a (Signed)--- - - ------- -------------------------- -- --....(Owner and/or Contractor) - --- ----- By:. = Z - [Title] - (Plot plan, showing size of lot, location of system in relation to wells, buildin s, etc., can be placed ineverse side). FOR DEPA MENT USE ONLY APPLICATION ACCEPTED BY------ - ------ -------------- DATE --- REVIEWED BY--------------------------------- -------------------------------------------------------- DATE------- --- --- ----------- --- ----- BUILDINGPERMIT ISSUED-------------------------------------------------------------•--------------------- ---------------- DATE------------------------------------- ---------------------- Alterationsand/or recommendations:------------------------------------ -- -----------------•-----------------------------------•---------------------------------------------------------------- --------------------------------------- -----------------• ------ ------------------------------------- ------------------------------------------------------------------------------------------------------------.. ---------- --------•---- ---------------------------------------------- - --- ---------------------------------------- ------------------------------------- -----•-----------•-------•-------------------------------------- ------------------------------- --------- ------------------------------------------------ --------- ------------------------------- -- ---------------------------------------------------- -- ----------------------------- -------------------------------- ---------- --- ------------------------•------------------------------ - --------------------------------- ------ -- ---------------------------------- ----------- ----------------- - EINAL INSPECTION BY:. � r------ Date/ T L/ ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205-West 9th Street Stockton,California Lodi,California Manteca,California Tracy, California F.P.CC.