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1-UKUrEiC:E USE: ------------ -------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. _ .. -------------- •---- ---- ---------------- -- (Complete in Duplicate) ------------------ This Permit Ex ires 1 Year From Date Issued pDate Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install}he work k�rein described, This a plication is made in compliance with County Ordinance No. 549. JOB ADDRESS AND CATIO - -- Ive,6--- -Q V__ ti_ ------- --- ----------•---------------- Owner's Namef ----- •----- - = ------------7--- Phone ----- Address....... 'r -- ----' ---------- Contractor's Name----- ___-• •- _ - r - • -•------ - --- Phone Installation will serve: Residence/ Apartment House ❑ Commercial [:1Trailer Court ❑ Motel ❑ Other [:1 Number of living units: _ --- Number of bedrooms___ Number aths _/_.-_ Lot size ------ --- ----••-------------- Water Supply: Public system ❑ Community system [] Private Depth Water Table 24?ft. Character of soil to a depth of 3 feet: Sand E] Gravel [] Sandy Loam Clay Loam [] Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date----_-----_---_--I No ❑ 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-------- TY Mspos Field: Distance from nearest well-... �_-_Distance from foundation___._ 11----------Distance to nearest lot line__�_______________ Number of lines------------l__---__________ _._ Length of each line-____,�_0d-,/-_______-_-Width of trench----�2--- Type of filter material_-:-Depth of filter material------1--� ----Tota! length---_J-0-U----------------------- 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 foundstion-------------------- material____----------------------- � ❑ Size: Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. 1 Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--------------- ---- � t❑ Distance to nearest lot line-------__________________._ Remodeling and/or repairing (describe):----------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------- --•--------------------•-----------------------------•--------------------------------------•--------------------------------------------------------- ----•------------------------= ------------- ---------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun ordinances, State ws, and rule and regulations the San Joa ty Health Din Local s#rict.- G � (Signed)------ d/or Contractor) BY: ---------- ------------------- -- - -----------------------------------------------[Title)------------------- -- ----------------- -- -- -------------- I (Plot plan, showing size of lot, location of system in relat- n to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ -- - _ -- ---------------------- w�3 DATE - -- ------•----------------------- REVIEWEDBY-------------------------------- ------------ --------------------------------------------------------•--- DATE----------------------- BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DANE -- -------------------------------- Alterations and/or recommendations------------- ------------------------ -----------------------------------------------------------------------------------------------•------------------------------•------•-•-------••---------- ---- ---------•--------•-------------- ---------------------- ------------------------------------------------------------- ---------------•--------- ------------------ ----------------- ------------------------------------------------- FINAL INSPECTION BY:. - -- -�n y - .1 Date -�. . 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 E5 9 REVISED 8-89 3M 3-'63 F.P.CD,