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FOR OFFICE USE: _ �+ -------------------=-- ------ Permit No. - r _ APPLICATION FOR SANITATION PERMIT / ------------ {Complete in Duplicate} Date Issued ------------------------ TF+is Permit Expires 1 Year From Date Issue 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. S49. JOB ADDRESS AND LOCATION--- 'T __...�ra-- Owner's Name--; __ r ------------------------------ Phone--------------------•------------ , Address____ Contractor's Name--------------------- _ _ ----•-••-----• Installation will serve: Residence IM Apartment House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___I___ Number of bedrooms __3__ Number of baths __I__.. Lot size ____- _a.�-------------- ---•-- � Water Supply: Public system [N 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 (3 Previous Application Made: (If yes,date--------------------1 -No F1 New Construction: Yes 2 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----!42-----___._.Material -._-_ _ K✓'a��_4'_..______._.-. ® No. of compartments---------Z_ -------Size---- ----Liquid depth--------VA., —'-------Capacity........ Disposal Field: Distance from nearest well_________________Distanceorp ouugda--fi n..;.-ia --.D-stance to nearest lot;line______b_'_-__- i m Number of lines--------------- =- ------Length o eat En = Distance of trench------2 ----------------------- Type of filter material----!QQ_C 4-------Depth of filter material------t.-b'____ -------Total length______ ______________-__ -- Seepage Pit: Distance to nearest well-----._--------------Distance from foundation_____--______-_-.Distance to nearest lot line-------_-------- F-1 Number of pits----------------------Lining material---------------------..Size: Diameter---------------------Depth--------------------------------- 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 (describe):------ ----- ------•------- --------------- •-------------------•-•-------------••-------------------------------------- --------I----------------------------- ------------ - -- -------------•---•------------------•-------------------••--------•------•-----------•-•---------•------------------------------------------------------------------._...--------------- I hereby certify that I have prepared this application and that the work will be done in accordanc6 with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. __.Owner and/or Contractor (Signed}---- _ � ----•-1 --------- - ( } --•----------- Title (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY '----- ------------- -- -�--------------------------------------- DATE----% �� .. --------------- REVIEWED ------------ - REVIEWEDBY ----•------------ DATE--------------•---------------------------------•---------- BUILDING PERMIT ISSUED------------------------ ------------------- DATE. Alterations and/or recommendations--------------------------- -- ------------------------------------•-------- -------------------•--•------------------------------- ---------------------------------------- --------------•-------------------------- ------------------------ ---------.--------------- --------------- - ------- ------ ------- ----------------------------------------------------- ------- f FINAL INSPECTION BY:.-�-- ------------- Date------ -/-Zl---------- r' SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Strut 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E9-9 REVI9EC 6.39 F-F-CC.ZM 6.60