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FOR OFFICE USE: -------- --- Q APPLICATION FOR SANITATION PERMIT Permit No. I�I�J-- > (Complete in Duplicate) ------------------------ '=---• - Date Issued -�ar�___'�: --------- - �._ --- - _ ..... _.._ TFIPermit Expires 1 Year From Date Issued Application is hereby a to the San Joa i .Local Health District for a permit to construct and install the work herein described. This application is ma a in compliance with County Ordinance No. 549, JOB ADDRESS AND LO ATION- - - • -� ", - s ------- --- Owner's Name � - Phone ---------------------------------------------- Address - " ------------ —�-E�-�------ ------ -------•-----------•-- Contractor's Name--- _- �.n.� = --------------------------- - ------------------------------------------. Phone----------------------••----------- Installation will serve: Residence V A artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms j__._ Number of baths -1----- Lot size `Y''-------------•---------------------- Water Supply: Public system ❑ Community system ❑ Private [j] Depth to Water Tableak'P-_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe J� Hardpan-Eff Previous Application Made: (if yes,date......... ..........1 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-----?6S' --Distance from foundation -------.Material_--------------------____________________________ ❑ No. of compartments---- -----------------_-Size------------------- ------------Liquid depth_-------------------------Capacity--..------------------- Disposal Field: Distance from nearest well__7!—--------Distance from foundation---3a-----------Distance to nearest lot line__-_/---_.___-- _ � 50 Number of lines_._.______ __________________ Length of each line___---/�-- ___.._---- Width of`trench.r.__. ----______________-_-- s Type of filter materia__ Depth of filter material_._._/-__..___.__._Total le ng th_ _____________________________ 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----------------------------------_- El Size: Diameter- -- --------------- ----------------Depth--------------- ------------- ---------------------Liquid Capacity---------------------------gals. 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 lone in accordance-with San Joaquin County -with ordinances, State laws, and rules and regulations of the San Joaquin Local Health istric+. �] (Signed)---- ------- ---------------- --------- - (Owner and/or Contractor) � ---bit-- -- =�-- --- - - --------------- --- - --------- Tale By:------------------------------------------------------------------------- ---------------------------------------------------------( )-------------------: (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side).:: 40i .: FOR DEPARTMENT USE ONLY y , APPLICATION ACCEPTED BY �'{ DATE.-� -- -` REVIEWEDBY------ -------------------- ------------ ------------------------------------------------------------------- DATE----------------------------------------- ---------------- BUILDINGPERMIT ISSUED.------•-----------------------------------------------------— ----------------- ------------------ DATE.----------------------- -------------=------------- Alterations and/or recommendations:------ ---------------------- ----------------------- Date-4A_ r - -------------------------------------------- SAN - - FINAL INSPECTION BY: .. - - ---.�t�'- — --------------------- - � - - - ------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazollon Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CC.