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FOROFFICE USE: ----- ----- ------- ------- -- --- --- ---------------- APPLICATION FOR SANITATION PERMIT Permit No. 0� ------- ---- ----------------------- -------------------- (Complete in Duplicate �` r --------------------------�_..._..._.._.__-..._-.-__..___ This Permit Expires i Year From Date Issued Date Issued .________/Q._____ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. T ism application is_ma_de in compliance with County Ordinance No. 549. JOB ADDRE LOC TION A(r-, �'' "uc�'''� ` ` ' ------------------ Owner's Na Phone------------------------------------ Address---------- ----•--------------------------•---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: Publics stem Community system ❑ Private [Depth to Table -------- ft . Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: 11 yes,date-------------.------I No ❑ New Construction: Yes_[] No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS:_ Y u (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest weff-----------------Distance from foundation--------------------Material --____._._____.____--..---__----..---- ❑ No. of compartments--- ----------------------Size---------------------------- ---Liquid depth---------------- ---------Capacity---------- ------------ Disposal ieid: Distance from nearest well.. `_._Distance from foundation----/c-........-Distance to nearest lot line-S--/-.---- Number of lines-__.-__----Y...............-Length of each line__._.__�2-__..______.Width of trench.-.._ -- -_-._1_---____-_-__-� Type of filter material------.___a. _..1-.----Depth of filter maferial-'_11-.,,-----Total length---------1--q o.....-_-_-._......_ See pag if: Distance to nearest well-------._/6b.'__ Distance from foundation---- .h?_'.------.Distance to nearest lot line__�r._.1________ Number of pits--------- Lining material-------- .Size: Diameter.-------�3 ,r --Depth---- -cS�__�---------------- Cesspool: Distance from nearest well-----------------Distance from foundation....................Lining material______-_--..---.-.-.--.-._.-____---- VV ❑ Size: Diameter----------------- -- ---- --- -------Depth.------------ ----------- - ------------------.-Liquid Capacity---------------------------'gals. Privy: Distance from nearest well-----------------------.-------------------------Distance from nearest building-.. ❑ Distance to nearest lot line--------------------------------------------:------------------------- ------- ---- - j Remodeling and/or repairing (describe= -----------------------------------------------------------------------•--------------------------------- -------------------------------------••----------•---------------------------------•--------I-•--------------•---•---------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------•-------------------------- ----------------------------------------------------------------- ------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------- -------- -------------- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County, ordinances, Sta aws, and rules and regulations of the San Joaquin Local Health District. 3 (Signed)-------- ------------------------ and/or Contractor) T BY:----------------------------------------- ----'--------------- --------'`'--"`--- --------------------------------- - -----(Title}-- -- - -- �------- ----------- ..-..--------------- (Plot plan, showing size of lot, location of syste in relation to wells, buildings, etc., can be placed on reverse side). i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE �-------7---------- -------.-- - - REVIEWEDBY------------------------------- -------------------- ----- -------------- ---------------------- -------------------------- DATE---•---- --------------------------------------•----------- BUILDING PERMIT ISSUED----- -------------------------------- ---------------------------------------- ----------------- DATE----------------------------------------------------------- Alterations and/or recommendations:--------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------- --------------------------------------------- ------------------------------------------------------------------------------------------------------- ------------------------------ --------•---- -------------------------- ------ ----------------- t ---- -- -- - -- ------ ------ ---------- ---- ------------------•------------- ------------ --------------------- - ------------ ----------- - --------------------------------------------------------------- FINAL INSPECTION BY; Jf --------------- -- -------- Dafie ~ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi, California Manteca,California Tracy,California F.P.CO. r