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FOR OFFICE USE: --------------------- --- -- --------- ---------------- APPLICATION FOR SANITATION PERMIT Permit No. ------------------------ ------ (Complete in Duplicate) Date Issued -----._.___ This permit Expires 1 Y ar Fro3h 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 t� C ty Ordinance No. 549. JOB ADDRESS AND CAT ON.--,��----- --------- ----- ------------------------------------------------------------•-- Owner's Nam — -- - ---- Phone L/ S---�J��S Address ----------- // ...// Contractor's Name-------- Phone.,!/-45..---�--/yo7i Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ f Number of living units: ._.- Number of bedrooms --7-. Number of baths _. _ Lot size ._--54.--. -------f --------------------- 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: Ill yes,date----------------.---) No (Pr 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.) eptic Tank: Distance from nearest well_---------------Distance from foundation--------------------Material-------------------------- ---- ------------ No. of compartments------------ -----Size--------------------------------Liquid depth---------------- ---------Capacity----------------------- p field: Distance from nearest 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 length------------------------------------------ Seepage ______.__.--_-------------------------Seepage Pit: Distance to nearestwell __-..Dista, m foundation---- -�?�.---.Distance to nearest lot line----- ------- Number of pits----/------------Lining material , 4._ ....Size: Diameter---�3.--'...-.--Deptn._.... S-.............. Q 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 �clescribe):----- - --- ---- -------------------•----•------------------------------------•-------------------------------•--------------------•--- ------------------------------------- ---------------------------•---•--------------------------------------------------------------------------------------- -------- ----------- ------- ---------- 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} r (Plot plan, showing size of lot, location of system in r wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- ----------------- ------ -------------------------------------- DATE---------1 Jlf l -------------------- REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE---------------------------- BUILDINGPERMIT ISSUED------------------------ ---- --------------------------- DATE---------------------- ------------------ ------------------- Alterations and/or recommendations:-------- .. �.----. --r -------- - -- - --------------- ----- -------------------------------------------------------------------------------- - --------------------- ------- ------------------------------------------------------------- FINAL INSPECTION BY:. Date f.. - -------------I--•- -- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California