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FOR OFFICE USE: - APPLICATION FOR SANITATION PERMIT tk- ---Permit No. ____ __________ ______ . ----------------- - --- ------W----------------- ---- -- (Complete in Duplicate) --- This Permit Expires 1 Year From Date Issued Date Issued ______________--------- Application is hereby made to the San Joaquin Local Heal+h District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION----------------- ---------------------r t ---------------�Yr�,----------------.------------�------- Owner's Name-------------- = Ahone.- ..�i -< 3 , rte. Address -------------------•--------------------------------------------------------------------------------------------------.....--•---------------------------------- Contractor`s Name -------------------------------------------------------------------------------------- Phone------------------------------•--- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court p Motel ❑ Other ❑ Number of living units: ________ Number of bedrooms ________ Number of baths ......... 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 ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made. (If yes,date_f_________________) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: - w " (No septic'tank or cesspool perm'W d�ff puk l c sewer is avail��e wit in' 2D0 feet:)" Septic.•Tank: Distance from nearest well-----------------Distance from foundation_.______________.Material_________________ ❑ No, of compartments------ -------------------Size------------------------- ------Liquid depth--------- ----__--------Cap city-.�--- `-,------- Disposal Field: Distance from nearest welf.................bistance from foundation__.__...____.___..Distance F1 Number nearest lot line------ g 1 . . Number of lines------=--------------------- Length df each fine----------_--------- - 1--...Width of trench_,--i-------:--•------------------ Type of filter material-------------------------Depth of filter material-----------------------Total length___________a------------------------------ Seepage ____-_________-__----_______Seepage Pit: Distance to nearest.well----------------------Distance from foundation--------------------Distance to nearest lot line__.__.________.-- I ❑ Number of pits----------------------Lining material-------------.---------Size: Diameter.------------ - --.Depth--,_J-------------------------- l t 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- ------r------------------------------------------ Remodeling ----------------------------------------emo a ing and/or repairing (describe)-------------------------------------------------------------- --------------------=-•----------------------------------------------------------------- ----------------------------------------------------------------- `-------------_--------------------------------------;------------------------------------------------------------------------------- ------------------ le- ------------------------------------------------------------------------------------------------------------ :=------------•---------------------------------------•--------•--------------------•---------- 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, and rules and regulations of the San Joaquin Local Health District. (Signed) ` .. r ------------------------------------------(Owner and/or Contractor) 9 )-------------- ------ '-4 BY —- ------------- ---------------- --------.---- — "" } = =- ------------------- -(Title) - ------------ - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can 6e' placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- -------I- ------ - ------------------------------------------------------- ----- DATE.------------------------ - REVIEWEDBY----------------------------------------- --- ----------------------------------------------------------- ------ ----------- DATE BUILDINGPERMIT ISSUED-------------- -------------------------- ------•--------------------------------- --------- ------- DATE--------- ----------------------------------------------- Alterations and/or recommendations.___ --.,.�" -.- --- -- - ,- - ---- ---------------------------- = ---------------------------------------------------------•--------------------- -------------------------------------------------- ---------------------_----------------------- - - --------------------- FINAL INSPECTION BY------ - - --------------------------------------------------- Date------------------------------ - SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Hazellon Ave. 300 Wesi 07 k Street 114 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Trtrcy, California F.R Ca. . r