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FUX OFFICE USE ' ----------.t_------------------------ -------- --------- APPLICATION FOR SANITATION PERMIT Permit No. ' ------------ ------ --------------------- --------------- (Complete in Duplicate) -- -- This Permit Expires 1 Year From Date Issued Date issued _ -: ,5-_�� 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. JOB ADDRESS AND LOCATIO __-- _d_z G Owner's Name------& - ' Address ---------- Phone-----------•----------------------- ---- ------------------•------------------------------ ------------------------ G Contractor's Name-----�._.5--/-- ----------------- .------ Phone----------------------------------- Installation will serve: Residence ®impartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. _�.-__- Number of bedrooms _-tl,- Number of baths _-.2— Lot size Water Supply: Public system [�-�Community system ❑ Private ❑ Depth to Water Table --49ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe g''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 nk,: Distance from nearest well-----------------Distance from foundation--------------------Material ------_____---.--..-------------------.--------- ' No. of compartments--------------------------Size-----•.----------- -------------Liquid depth-------------------- -----Capacity------ ---------------- Disposal Field: Distance from nearest well----------- Distance from foundation--------------------Distance to nearest lot line.------._-_----- ❑ � Number of lines-----------------------------------Length of each line-----------------------------.Width of french.---------------____-- ------------- Type of filter material------------------_.----Depth of filter material--------------.--------Total length------------------------------.---.------- Seepage Pit. Distance to nearest well--------------------Distance from foundation--/D-------------.Distance to nearest lot line---�-__.-----_ O �R/W Number of pits---.-I----------------Lining material--.-*?v.�_-Size: Diameter---- Depth---�S_'_-----__ Q , 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 ------------------------- -------- --------------------------•---------------•-------------------•---------------------------------------------------------------------------•---------------------------- - 'r that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and r les and regulations of tate San Joaquin Local Health 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----- REVIEWED BY------ ---------------------------------------------------------------------------------------------------------------- ----- DATE---------- ----- - BUILDING PERMIT ISSUED---------------------- = - -_ ------------ DATE.-- - ------- __Alterations and/or recommendations:___-_✓,� ._.._.._____ .. _ r .__1��! �� --_--_---- ------------- ----------------------------------------------------% � - -�� ------------------ ---------------------- ---------------------------------------------------------------------------------------------------------- ----------------- --------- -------- -------------------- - ----------•------------I---- ----------------------------- - ------------------------------- -----------------__------------------------------- ------ - -------------------------�-- -------------------•------------------------------- ------------------•--------------------------------------------------------------------------- FINAL INSPECTION BY:. /`_--.. ----- -- --- Date--- - ---- -�7 C� ------------------- 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.F.0 O. 9