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FOROFFICE USE: -------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .r�� ----------------------------- ------- -- --- ----------- (Complete in Duplicate) ------------------._. This Permit Expires !'Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application/)s�fr�ade_incgrrlianc with Ordinance N 549 eq y�` � • JOB HIDDR 5 AND LOCATION: ----c'r � --:- - --- - %--/_, .�------------------�I_.._-- �cc ------ Owner's Name____-_'r __ _._ �1- Phone----------------------r Address---�! .._/--`�-. -- - - �__' _' Contractor's Name------- ------------------------ -------------------------------------------------------------- Phone--------------------_-_--------- Installation will serve: Residence partment House ❑ Commercial C] Trailer Court F] Motel F] Other ❑ Number of living units: ---I-.- Number of bedrooms - Number of baths _11--/Lot size _�-_�-n-"''�-�-�----------------------------- 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)k New Construction: Ye No ❑ FHA/VA: Yes ❑ No elf TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if 0c sewer is available within 200 feet.) Se tic Tank: Distance from nearest wells t'f�p. istan frofrrt, oundatU"a__. �__-__.,Ij�laterial____� _ 1. No. of compartments_- -.-�-_- ----- Size- -.__ _l__._ l_Liquid depth_L_ ___ _________�__J___CapacitY _ (�- __ a_�D' /C79a � Disposal Field: Distance from nearest welL�_ __ .__ _ istance from faun tion____ .___ ,� Dis nce to nearest lot`linF---------------- Number of lines___ '____ _Length of each line _. _______-. _ . idth of trench..�__`-'______________________ Type of filter material- ' Depth of filter material r( _._...Total length_- _ __(?----------------------- Se page Pit: Distance to nearest well__-------------------Distance from foundation--------------------Distance to nearest lot line--.------------_ ❑ Number of pits----------------------Lining material------------.----------Size: Diameter-----------------------Depth.-----------_-------------------- Cesspool: Distance from nearest well-----------_r-----Distance from foundation--------------------Lining material--------.__________---__-_--_._-.-_ ❑ Size: Diameter------------ ------------ - ----- ----Depth----------------------------------------------------Liquid Capacity----------------------------gals. �4�r Privy. Distance from nearest well.-..-!-------------------------------------------Distance from nearest building___..__..-._-------------_.----_---------. ❑ Distance to nearest lot line----'---------------------------------------- ------------------------- -------------- ----------------------------------------------------- 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 C - - ---- -'-��'---- -- ------`-'----'-�--r-----'- --- --- �--� ordinances, S#,te laws, and rules and regulations of + e San Joaquin LocalHealth District. (Signed)__ _ (Owner and/or Contractor) By-------------------------------------------- ---- -- ----------------------------------------------- --------------------------(Title)----------------------------------------------------------------------- ------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). • FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------- -- _._---_ DATE_-.-____-_-_-___- - --------------------------------------------0__ ---------------------------------------REVIEWED BY------------------------ ------ - ------ --- ----------------------- ------------------ DATE- BUILDING PERMIT ISSUED---•---------------- DATE.-- _--��--------�� - -------------------------- Alterations - -------------------- Alterations and/or recommendations:---------------------------------------------- --------•_--..------------- ----------------------•--------------------------•---------------------------------- ------------------------------------ ------------------------------------------------------------------------ ----------------------- ------- - ----------- ---------------------------------------------------•------------- -------------------------------------------•----------------- ------------------------------•---------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:.. a, - ---------------- Date -- --------- ------------------------- -------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 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 C.