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FOR OFFICE USE: ----------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit i� � .9. -- �� PDuplicate) Date Issued ---,I-_:c - f Com lete-in This Permit Expires 1 Year From Date Issued 0 q —Zd0--17 Application is hereby made to'�fhe 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. T7S, 0eO ;1 JOB ADDRESS AND LOCAT�IO�N_________C .i�___� . .-__ �c .__ _ ___ _ ._ _._ tl_ 1-_-__ __ Owner's Name- ----- - = Phone---------------------------------- Address-----•-�---- _ .___.. ------------------------------- ----- Phone------ --------•--------••--------- Contractor's Name installation will serve: Residence [Apartment House ❑Z Commercial E] Trailer Court ❑ Motel E] Other ID Number of living units: _I!r-_ Number of bedrooms _3.. Number of baths__?Lot size ---- i Water Supply: Public system ❑ Community system' ❑ Private [,Depth to Water Table ...... _ ft l Character of soil to a depth of3 feet- Sand' '--❑ Gravel D.,ASan'dy Loam [Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan a Previous Application Made: (If�yes,date_-__--__._.._._ ) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑j TYPE OF INSTALLATION AND SPECIFICATIONS: ;; (No septic tank or cesspool permitted if public sewer-is'available within 200 feet.) Septic Tank: Distance frl'm nearest well-________________Distan ifro founda�ion___-1.`._______.Material ._.____._ _._..___ ...._ ___-- R S. /f` - _ei'_-s__Liquid depth_.__.... .. . Capacity No. of com�partments...__. ..1,. _.. Ca acct Icrd t Dispos Field: Distance from nearest well...... p�..._Distance from foundation---.!�a .__...-Distance to nearest lot line_s�_____._____ Number ofilines______________ g ---- --- -------Len th:of each line__.7s".7•S.!-_9Q.Width of trench__-z.�_._________-_..___ -------- Type of filer material--------4.!....._Depth of filterimaterial---I1-`'___._._..Total length---- ------------------ Seepage Pit: Distance to nearest well...................... from foundation___________________Distance to nearest lot line__.______._.___- " ❑ Number ofl�pits--. ------------- ..'Lining material---------- ...... Size: Diameter_....................Depth--------------------------------- Cesspool: Distance from nearest well _______________Distance from foundation----__-.....----- - Lining material-------------------------------------- El Size: Diameter- -- -------------- ----------------Depth------------------------- ------------------ ...Liquid Capacity------------------ ---------g a", ` Privy: Distance from nearest well--------..---------------------------------------Distance from nearest building-------.._------------------- ❑ Distance to� nearest lot fine ------ --------- ------------------------------------------- ---------------------------------------------- --------- -- ------------------------ --------- - -- - Remodeling and/or repairing (describe):------- -------------- - -------•-•---•--- ---------------- --------------------------------------•-------------------------•--- --- Li ,IM - --------- ------- - --------------------------1-------------------------------••------•--------------------------------------------•----•----- •---------------------------------•-------- -------- -------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State ws, and rule's and regulations of the San Joaquin Local Health District. (Signed) - ---- --- and/or Con+Tactor) -- ---- ---- ---- BY� ; y --- ---- -- - ------------------------- ----------- -----(Title)--------- ------- ---. --------------------------------- - - (Plot plan, showing size of lot, location of system in elation to wells, buildings, etc., can be placed on reverse side). II, FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_-- _ -- -- -- -- Wit --------------------------------------------------- DATE._. ._ -_J_' o. - -__ ------------------- REVIEWEDBY------------------ ----- 11M---- -- ------ --------------------------------------------- ------ DATE------ --------------------------- ------------------------- BUILDING PERMIT ISSUED--..-- - - ------------ DATE---------------- --------- �I Alterations and/or recommend- ------------ ---------------------------------------•----._.recommendations: ------------- ------------------ --------- --- ----------- ----------------------------------------------------- ----------- ------------ --------------- I --------------------------•---------- ..--------------------------------------------•-------------------'-------- - ---------------------•---------••---------- -------•-- I1---.................... .--- -- -------- -------------------------------------------- ------ ------------------------------------- ------- --- -- ------ - - --- ---- --------------- ---------- I - -------------------------------------------- - I t FINAL INSPECTION BY: - -------- ------------ x_t'-.01-:7-'---- --------------- -------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Noxeltan Ave. 300 West Oak Streel 124 Sycamore Street 205 West 9th Street Stockton,California Lodi. California Mantecar California Tracy,California E.H.9 2M 1-67 Vanguard Press