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ivRvrrik,[ uor: —^— '------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .c _j_ �✓- ------- -----I------_----- --------------------------- (Complete in Duplicate) --- -------- - F------ - ------ --- This Permit Ex ires i 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_a.pplication.,is-made in comp lance with County Ordinance No. 549. rPZ2caA. ll!_ H !6-"46JAref JOB ADDRESS A LOCATION__--- _ �f ' p �s r ......... ---�---------p�-1-.. _ Owner's Name-' l�f --r.�.c ,------ ----------- Phone--------------------------------•-- Address------- Contractor's Name ----- --------- - - -------------•----- -•-•--. Phone Installation will serve: Residence E] Apartment House El Commercial [Trailer Court ❑ 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----------..........) 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-----..-ra_`_Distance from foundation_____�o_�_-____.Material____... - -.-.- n�+ �� L No. of compartments-----------y---------Size--�x..�-f_1_4_x._-_-Liquid depth-----I/-- ---------------Capacity--/ Dispose field: Distance from nearest well_.�'�_`_ Distance from foundation_-/_fd_.`---------Distance to nearest lot Number of lines_._____-___-� .- - length l-i-n- -e-_-----_----------- NO , ._--------- --- Length of each line-------/-�-- ------.Width of trench-----�- Type o i ter material------ ------Depth of filter material-------I-�-i-t- .Total length------- -------------------------------- Seepage --.--- Yu___________._____- - --- Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line--------------__ ❑ Number of pits----------------------Lining material---------------------.Size: Diameter----------------- - ---Depth--------------------------------- esspool: Distance from nearest well_________________Distance from foundation--------------------Lining material---------_---..________.____-_-___.__. ❑ Size: Diameter---------------------- ---------------Depth---------------r-------------------- --------------Liquid Capacity- ------------------------gak, 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 ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)----------------- ---(�+ and/or Contractor) By: ------------------------------------------------ (Title- -------------------------------- - - - -- ---- (Plot plan, ---- showing size of lot, location of system in relation to wells, buildings, etc., canbe placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCT PTSD BY--- -- - --- -- -- ---- ---- --- -- ------ DATE_._''_-- hj ------ -- -------------- REVIEWED BY-------------------------------- ------------ ------------ ---------------------------- ------------- ------ DATE----------------- -- - -------------------------------- UILDING PERMIT ISSUED---------------------------------- ------------------------------------------------------------------ DATE. - --------------- aerations and/or recommendations:----_._.-_.___.__. FINAL INSPECTION BY:-- - - - -------------- Date__!J____ ---` ------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi, California Manteca,California Tracy,California F.A.0 O.