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FUR OFFICE USE: ------------------------------------------------------- -- -- ------------------------------------------------- ----------------- ---------------------------------------------------------- __.-_______- APPLICATION FOR SANITATION PERMIT Permit No. ----------------------------------------------------- -- (Complete in Duplicate) 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. X4¢0®this application imade in compliance with County Ordinance No. 549. 030-1S JOSADDRESS AN CA . ON.- ---- -- -J - -- --- ------------------------------------------------------------------------------------------ Owner's Name__ '1 Address ------ ...._2, � s-- Contractor's Name-_. - --------------------------------- ------------------ --------------------------------- Prone------------------•---------------- Q Installation will serve: Residence j-'_A�partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:/__-_ Number of bedrooms _c2- Number of baths _c_- Lot size ___-_ ____.___ Water Supply: Public system ❑ Community system ❑ Private Er-Depth to Water Table __;5� ft. r Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [!r"Aclobe ❑ Hardpan ❑ Previous Application Made: (If yes,date_________ __--------) No ❑ New Construction: Yes No ❑ FHANA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 1,2 ( ( Septic T k: Distance from nearest _Distance from foundation__.,/G7__-____.Material__ ��_ ------------ No. of compartments___________ _.-__Size_`_f�5►JAS- --_q _ __Liquid depth Ca aci Disposal Field: Distance from nearest well-,SZ.F_____Distance from foundation_-l-S_____-_-Distance to nearest lot line----- Number ---Number of lines-----------------------------------Length of each line_-?r�-------------------Width of trench/�Q-- •----------------- Type of filter material �_ �_�i� Depth of filter materiaL_,Z _��_____Total length- . ___ __ ':-.____ `V Seepage 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_----------------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---------------------------------- --------- ------------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe)-------------- ----------------------------------------------------------------------------------- ---------------•------------------------------------ ----------------•--------------•-----------------------------------------------------------------------------------------------------------------------------------------------------------•-------------------------------- ---------------------- ------ ----------------------------------------•---------------------------------------------------------------------------------------------------------------------------------------------- I Hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Je law ,and^rul and r guI tions of the San J�aquin Local Health District. (Signed) '' ---- ---------------------------- (Owner and/or Contractorl By: ------------- - - -- --- --- ----- (Title (Plot plan, showing size of lot, location of system�in�on fo I buildings, etc., can be p ced on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------------------- DATE---- G•+ REVIEWEDBY---------------------------- ------------------------------- DATE------------.------------------------------ BUILDING PERMIT ISSUED--------------- ----------------------------------------------------------------------- --------------- DATE--------- ------- ------------------------------------------- Alterations and/or recommendations:------------------------- --- ------ - ------ ----------------------------------•-----•-------------------------------•------------------------------- ------------- ------------------ ------------ ------------------------------------------------------------ -------- ------------------------------•-------------------------------------- -------------------------------- ------------•----------------------- -----------------•---------------------------------------------------------------------------------------------------- --------------------------------------------- --- ------------- r F€NAL INSPECTION BY:_e --------- Date '�1� ��'' b ---------------------------- ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E,Maselton Ave. 300 West Oak Street 124 Sycarn ore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CO.