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FOR OFFICE USE: - -- ------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permif No. ....... ............... (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 descrbed. This application is made in compliance with Cou,�Ordi nce No. 549. ' II JOB ADDRESS AND LOC ATIN.O - -------- - --- - - •---------------------------------------------------- Owner's Name--- -1trr>� ----------------------------------------------- Phone 74__ -__._..110--f___________ -I____ ______-___.-._________________._._______.____ ______-_____..______-- Address--•--- /��- --- ----------------• - � ------ ff a ' ---------•--._. Phone-------•------------••---•-•------• Contractor's Name---- ---- - ---- ` Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/._--- Number of bedrooms __. Numbf baths _;V__Lot size ---- _ __ _ ._ --------------------- Water Supply: Public system 171 Community 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,dafe---------_---------) No F1 New Construction: Yes E] No E] FHA/VA: Yes [-INo ❑ 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__- Qr.._Distance from foundation----/_O_._._-Material__. No. of compartments______? Size_ " "Liquid de }h------- Capacity - ap ... . el Dispos l Field: Distance from nearest well___- 11____Distance .from foundation..--f_Q-.__-.--Distance to nearest lot line_S__ Number of lines..--.----- ` __ Length of each line.-.__,S --------------- .Width of trench-�__ ______.__________-__ pp rr Type of filter material_______ ?_li--,_.__Depth of filter material_.(I --- Total length___./_�.z-___________________________ A-1$eep a Pit: Distance to nearest well------1__�_Q__----Distance from foundation---..t_______._.. Distance to nearest lot line__-4___- Number of pits-------'-.-.--- ----Lining material----6-A-'-------Size: Diameter-----33_"_--._._.Depth---- --s- ------ Cesspool: Distance from nearest wail-----------------Distance from foundation--------------------Lining material__._-______________._____.-_______.__. ❑ Size: €diameter------------- --------------- ----Depth_------ ---------------------------------- -------Liquid Capacity-_------------------------gals. Privy: Distance from nearest welL------------------____----------------- -.-.-Distance from nearest building___-.---__._._._--_________------.------- I ❑ Distance to nearest lot line---------------- Remodeling and/or repairing (describe):- -----------•---- -------------- -----•-- ------- 1 -1------------------------------------------------ --------------------------------------------------------------- ------------------------------ --------------- ------------- - ------- --------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I s and rules and regulations of the San Joaquin Local Health District. (Signed)--- -- u � r - ----------- ----------- ----------------------------- - -------------------------------- ------- and/or Contractor) CIA.— r) ----------- ----------------------------(Title)':__'-- �--� ------ --- BY r (Plot plan, showing size of lot, location of system i relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------------- DATE----- ----------------- ---- ---- ----- -- ------------ -- - ------------ ------------ - REVIEWEDBY---- - ---------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED-------------------------------------- -------------------------------------- DATE------------------ ------- -------------------------------- --------------------------------------------------------------- Alterations and/or recommendations----------------------------------- -------------- ------ --------------------------------------- - - F _______________ (4.. _ _ ____________________________________________________________________________._.____-_-_____.._-__----__--- r FINAL INSPECTION BY: l---------- - Date. �e� _47-------- ---------------------- ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California + F.P.0 O.