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FOR OFFICE USE: -- — - ----------------------------- ------------------------.___-------------------- ------- APPLICATION FOR SANITATION PERMIT Permit o. 1�_ZZZF . -- ------------------ ------------------ --------- (Complete in Duplicate) -------------------------- This Permit Expires 1 Year From Date Issued Date Issu _ -�� 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 - 4rljd� iI"-"r-."5" ------. 41 Ga ✓ Owner's Name_----- Phone--------------------------- �} _`- ----- --------- Address ---------------------- ----------------_-------------------------------------------------- Contractor's Name------ ----------- _. -------. --- Phone----------------•--------------- - Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -_�__ Number of bedrooms-'... Number of baths,.----- Lot size _ Water Supply: Public system ❑ Community system ❑ Private [3""Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [r-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'Tank: Distance from nearest well---_-------------Distance from foundation___________________M aferial ❑ No. of compartments--------------- ---- -----Size--------------------------------Liquid depth---------------- --------Capacity----------------------- Disp field: Distance from nearest well-___f-o_.'___.Distance from foundation-------�U.........Distance to nearest lot line------._'_----. Number of lines-------------1--------------------Length of each line------47- -------Width of trench._,z. '-------•------------- --.- Type of filter material___----L�_.n----__._-Depth of filter material.... ---------Total length--_._42- ---------------------------- Seepage ------------_-___-----_ Seep 9e Pit: Distanceto n+arest well ---- Distance efrom foundation--------------------Distance to nearest lot line__._--..---_-__.- El Number of P_ Lining ma------------------------Size: Diameter-- ----------- ....... Depth------------------- ------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material ____________-__.____--.-._ - ❑ .. Size: Diameter--------------------------------------Depth--------------------------------------- ------------Liquid Capacity----------------------------ga Privy: Distance from nearest well--__-------------- ------------------------..-Distance from nearest building---- ---.-_❑ Distance to nearest lot line------ ----------------------------------- --------------------------- Remodeling and/or repairing (describe)-------------------------------------------------------------------------------- ------------•-------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------•--------------------------------------------- -- ------------------------------------------------- ------------- ----------------------------------------------------------------------------------•---------•----------------------------------------------------------------------------------------------------------------- i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinancest State laws, and rules and regulations of the San Joaquin Local Health District. i (Signed) - ( iRr-and/or Contractor) BY k_1/�r�. . ----------------------------------- (Title) (Plat plan, showing size of lot, location of system in re ation tp wells, buildings, etc., can be placed ori reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- -- = DATE__s5�' - ._� REVIEWED BY............................. "s DATE-_ - BUILDING PERMIT ISSUED--------------------------------------------------------------- -------------------------- - -- DATE Alterations and/or recommendations------- ----------------=--------------------------------------------------------------------------------------------------------------------- ---------------- --------------- -------------- --------- - ...___ ----- ----------.-----------------------........-------------------------...------------------------------------------------------------------------------------------------------------..-------------------------_--------.-- FINAL INSPECTION BY:.. _. _. _ �_ Date. _-,-x -r - ---------------•----- -------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haielton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CO.