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FOR OFFICE USE: , X1,31-- APPLICATION FOR SANITATION PERMIT Permit No. ,.'2 --------------------------------------------------------- (Complete in Duplicate) Date Issued ---------- ------------------------------__---------._-_ This Permit Expires 4 Year From Date Issues{ 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 Ordinpnce No. 549. JOB ADDRESS D LO ATION--� -- ----------------------------------------------------- ------------------------ Owner's Name-- -- -------------------------------•--------------------------- ------- Phone----------------- ---- Address..---- -------- ------------------------------------------------------------------------------------------------------------------------•---•---•------------ Contractor's Name----------- ` ------------ •-- --------- -------- --------------------•-------------------- Phone----- •----------------------•---- Installation will serve: Residence [VApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --- Number of bedrooms _ Number of baths __ ___ Lot size _. ' ___________________________________-___t y, Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table 6!1_ tt_ �w Character of soil to a depth of 3 feet: Sand ❑ Gravel [] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Er--Hardpan ❑[ ,, Previous Application Made: (If yes,dote--------- --____..) No Pr New Construction: Yes ❑ No FHA/VA: Yes ❑ No m TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septi ,ankh■ Distance from nearest well_________________Distance from foundation--------------------Material-------------__.__-_______._-___________-- No. of compartments-------------- -----------Size--------------------------------Liquid depth-- ---------- - --------Capacity- ------- I / ` Disposal Fie Distance from nearest well.•.`_�_0_.__..._Distance`from foundati��o3}__/0._____.___-_Distance to nearestJat liner_______ Number of lines__._________ _________________Lengthiof each line_�,�7`____`_-_______.Width of trench....____�.__.`--------.--__.__-- Type of filter material--_�fLD.C+�........Depth of filter material_ ____.- ------ length----il'�_____________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation------.--------._ __.Distance to nearest lot ine__._________..__ ❑ Number of pits--- ------ ------- --Lining material----_- -- --------- Size: Diameter------------.- --------Depth-------------------------------._ Cesspool: Distance from nearest well------------------ from foundation....................Lining material_-_--______._._____.__.__..__-______ ❑ Size: Diameter-- - ------- ------- ----------------Depth---------------- -----------------------------------Liquid Capacity- --------------------------gals. Privy: Distance from nearest well__________________________________________ ___ __Distance from nearest building__.._ ------------------------ - -. ❑ Distance to nearest lot line-. ---A-------------------------- --------- - -•-------------------------•---------------------------- ------------ Remodeling and/or repairing (describe)------------------------------------------------------------------- ------------------------------------- -----------------------------•----------------------- ---- ------------------------------------------------------------------------------------------- ---------------------------------------------- ----------------- ---------- -------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------- 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, arules and regul ions of the San Joaquin Local Health District. (Signed)------------------------ ----------- - - ----------- --------.-----------------------------------------------------------------------------------(Owner and/or Contractor} Ey------------------- ------- ---- ----- ------- - ------------------------ ------------------------------------------(Title).--------------------- (Plot plan, showing size of lot, location of s tem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE----------- ------------- ATE ------------- - G------------------------- REVIEWED BY---- --------------------------------- --------------------------- ----------- -----•------ ---------•--- - ----------------- DATE-------- ---- ----------------------- --------------------------------------- BUILDING PERMIT ISSUED------------------------------------------------------- -- •----------------------------------------- DA•TE---------------------------------------------------------- -- Alterations and/or recommendations--------------------------- ------------------- ------------------------------------------------------------------------- ------------------------------------- ------------- --------------------- ------------------------------------------------- ------------------------------------------------------------------- --•---•------------------------------------------------•---------- ---•-•-•-----•-----•----------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------- -- . -----------...----------- -- --- ---- - ------ ---------------- --- ---- ------ ---------- ---------------------------------------------------------------- --- ---------------------------------- FINAL. INSPECTION BY:----- -.-_ _ Date------------ --'-_� S N J0 IN LOCAL HEALTH DISTRICT 1401 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.c;a. A