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FOROFFICE USE -------------- -------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .,1.! .�1 ...f --------------------------------------------------------- (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. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS A LOCATI --------------------- •------ - ------- Owner's Name ------ - -- ------- --------- Phon> ----------- ------ Address-------------------- --------------------------------------------------- ------------------------------------ Contractor's Name-- ----------------------------------------------------------------- Phone..4'C6V_b_ i Installation will serve: Residence Apartment House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ ___ Nu of bedrooms Number of baths ---I--- Lot size ___--_-- Water Supply: Public system ommonity system,❑; Private ❑ Depth to Water Table -_.----- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobeardpan ❑ Previous Application Made: (If yes,date.__..-__----__._--1 No ❑[ New Construction: Yes ❑ No HA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS:,eN o septic tank or cesspool permitted if public sewer is available within 200 feet.) Se Ta Distance from nearest well_________________Distance from foundation--------------------Material---------._.---------.--------------------------- No. of compartments--------------------------Size--•-----------------------------Liquid depf�------------------ "---Capacity----------------------- 000 no sal Distance from nearest well--h - Distance from foundation._ _ ..__Distance to nearest lot line------ Number of lines---- _�____`�t Length of each lin ----e-- -- -- Width of french__ �f.._ -� Type of filter materi 'Na bkj-Depth of filter material______ _�f Total length--------------- -- --------- Seepage Pit: Distance to nearest well-- --------- from foundation_____,_ ____.Distance to nearest lot line_-_--- Number of pits...I-------------_____Lining material_Ra-C4 ---- Size: Diameter_ _ ___ �t _ _ Depth-..�-��--------------- V1 Cesspool: Distance from nearest well-________________Distance from,i�oundation_____--.___.- p ----- .Lining material-- ------------------------------- ❑ Size: Diameter--------------------------------------Depth------------------------------ -------------------- Liquid Capacity----------------------------gals. Privy: Distance from nearest weft---------------------------_---------------------Distance from nearest building------------------------------------------ T ❑ Distance to nearest lot line------------------------------------------------------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe)---------- --- ----- ------------------------------------ ------- ------------------•-•------------- ---------------------------•------------------------ ---------------••------------•------------------------------------------ ----- --------------- ------------ -------------- ----- -------------h----------------- ---------------------------------------------------- -- --------------------------------------------------------- ------------- ------------------- •----------------------------------------------------------------------------------------------------------------- I hereby certify tha+ I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and re u'ations of the San Joaquin Local Health District. �^ r or Contractor (Signed)- ---- � -a---- ) By:--------------------------- ------ -- ------------- ----------- - itle) ---- ----------- -------- - ------ - ------- - - -- ------ (Plot plan, showing size of lot, location of system in relation t ells, ui dings, a can be ed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-----.--- =y DATE REVIEWEDBY------------------------------------------ -- -- ------------------------------------------------------------------------ - DATE------------------------------------------------------------ BUILDING PERMIT ISSUED----------------------- - - ----------- DA•TE------------------------------------------------------------ - ----------------------------------------------------------- Alterationsand/or recommendaflogs:----------------------------------------------------------------------------------------------------------------------------------•--------------------------- �+ � -------------er.1-14"---------------------------------------------- ---------- --------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------- ---- ------------------ --------- ---------- ----- ------ - ------ - ------ - - ------ --------------------------------------------------------------------- ----------------------------------- ------------------ FINALINSPECTION BY:-- .------.------------------------ ----------------------- Date........-,7Z--------. '. -------- --------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stackton,California Lodi,California Manteca, California Tracy,California F.P.CC.