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rUKUFh1U USt: ----------------------------------------- -- --------- ------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No - --------------------------------------------------- -- (Complete in Duplicate) --------------------------------------------- This Permit Expires 1 Year From Date Issued Date IssuedA11V 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 Ordinance No. 549. SCDIliaAC25 " • w_•� JOB ADDRESS AND OCATION --------- --------- / /�` "'` --------------------------------------- Of Owner's Name------d - - -- - -- Phone 00, ----------------- -•------------ ------ --- ----- ----------------------------- ------ ------------------------------------ Owner's Name - - ----- -- ---------------- r Contractor's Name----------------------- i1�--------------------------------------- - ------ ------------------------------.-. Phone.---------------------------------- Installation will serve: Residence k AAartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---E--- Number of bedrooms ---1- Number of baths ---p- ..ir�Lot size _. --------------------------------- 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 E Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date------------------ ) 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----------------------- n Disposal Field: Distance from nearest well../&O------Distance from foundatio/r-'*------------Distance to nearest lot line 7.....----- iZ) Number of lines--------I-------_p--.-- -----_Length of each line----6-Q_----__----------.Width of trench--- --------------------- Type of filter material��-R--..-.--.----Depth of filter material___ -`..........Total length---- -fl----- ----------------------- a See age Pit: Distance to nearest well--- Q-d.-.------Distance from f ndation-_--�Q_-_-----.Distance to nearest lot li __.k'_-__.--_._ Number of pits_-j-----------------Lining material_-�---Size: Diameter....33--1K.-.----.Depth--.,z ___------------.----- Cesspool: Distance from nearest well----------------- from foundation------------ ------ material------------------------------------- El Size: Diameter--------------------------------------Depth-------------------------- -------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building________-_.---_-___-.---------..---.___.-. ❑ Distance to nearest lot line-- --- -------------------------- ------------------------------------------------------------------------------------------------------------ Remodelingand/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 la�`ws and rules and regulations of the San Joaquin Local Health District. (Signed]-_----- -------- r-_. .-(Owner and/or Contractor) --- --- ------------- (Signed)-------- --------------•----------------•-• •------------------ -----------------------------------------------------------------(Title)---------------------------------------- -------- ---- --------- (Plot plan, showing size of lot, iota ton of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- -- - _ ------ -------- DATE----,?-- ----/'/- --_--------------___-_____------ REVIEWEDBY------------------------------------------------- ------- ------------------ ---- --- ------------------------ ------- ----- DATE-------- ---------------- - BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------- --------------- -• DATE------------------------------------------------------------- Alterations and/or recommendations:---------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------- ----------- -----------------------------------------------------------------------------------------------------------------------------. ... ---------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------/---------------------------------------------------- FINAL INSPECTION BY--- - ----- --- --- -- ---------- Date-----as--- -!__-_b_�---------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F•.P.CG.