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FOR OFFICE USE: ---------------=---------------------------------------- APPLICATION -------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ------------------------ --- ----------------------------- (Complete in Duplicate) A Date issued --------.... This Permit Expires 1 Year From 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 is made in compliance with County Ordinance No. 549. JOB ADDRESS AN OCATION-lt . --------- - - -- -------------------- Z_ Owner's "- Owner's Name------ ----- .. .. ---------------- ------ --------- Phone------------------------------------ Address-----------•-----_ ------- - ---------------- i----- Contractor's Name----------------- ----•--- ------ -+- ------- - - ---------------------------------------. Phone..--_----------- --------- Installation will serve: Residence ❑ Apartment House C] Commercial E] Trailer Court E] Motel ❑ Other Era, Number of living units: __/_--- Number of bedrooms"'.- Number f baths ---/--- Lot size -__-._:__ --__--. -____------------------ Water Supply: Public system ElCommunity system C] Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [ lay Loam p Clay ❑ Adobe ❑ Hardpan ❑ . i 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.) 1 F s Septic Distance from nearest wek-aC4 _-_.....Distance from foundatiggn----1_______._ Material-----_____-------------------------------------- :Z_ ---- ------------------------------ No. of compartments------- `-------- ----Size4�'.�_`x_ _�_JlCr Liquid depth--------��-----------Capacity--//P-C3 v_-_-_-__-- �� from foundation to nearest lot lined__ Dispas Field: Distance from nearest well_______ _________Distance - Number of lines------ .-_-___,R Length of each line_-_1p-D-------------.Width of trench__-_-2--_---______-------------- Type of filter materials _t_1� ____.Depth of filter material-----/-.h.._"_______.Total length__1C _."------------------------- Seepage Pit: Distance to nearest well-_...................Distance from foundation--------------------Distance to nearest lot line---------------- El 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 repa�lri rig_j describe):-------------------=M'_ -------- -------------------•------------------------------------•-------------------------------------------------------- ------------- ------------------ ------------------------------------------------- -------------------------------------------------------------------E--------i--------------------------------------------------------------------------------------------------------------------------------------------- ------------------------ ____ \ t. k_ I hereby certify that l 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 Contract By: -----------------------------------=--=---Title (Plot plan, showing size of lot, location of system in relate to wells,Ybuildings, etcT, can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BYA_ �-t. ---------------_-_____. DATE__1___._ AATT67 ---------------------------------------------- - REVIEWEDBY------------------- ------ ------------------------------------------------------------------------------------------------- DATE--------------------------------------- -------------------- BUILDINGPERMIT ISSUED--------------------------------------------------------- --------------------------------- --------- DATE--------------------------------------------- ------- -- Alterationsand/or recommendations: ------ ------------- ----------•----- - ---------••---------------------------------------------------------------------------------------------------- -------- ----------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------- ------ ---- ------------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------- ------------------------------------I------ ----------------------- ------------------------------- - --------------------------------------------------------------•-----•-------- ------------ -- ----- ----------------------------- ---- -------------------- ------- ----------------------•------------------------------------------ --------------------------- - - ------------------------------- FINAL INSPECTION BY:{.........."� -- - ------------------ Date... -. -- - ----- --------------------- ----------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Hazeilon Ave. 300 West Oak Street 124 Sycamore Street c205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California