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FOR OFFICE USE: ----------------------------------------------------- - ------ -- --------------------------------- ------------ APPLICATION FOR SANITATION PERMIT Permit No. . l ^ -------------- ------------------------------------ --- (Complete in Duplicate) Date Issued -----------_------------------------------__-------- .--- This permit Expires t 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. € • t �. � N e JOB ADDRESS AND LOCATION ----- �-- -------- ----------- ------------ -- ----------- --------------------------------- Owner's Name - -- -----------•- Phone Address------------- �----- 1 � ---= ----------- -- � -d--------------------------------- ----------------------------------------- . ---------- Contractor's Name -- ' ^t 'a - --- Phone------------------•-------••------- �. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ -q- Number of living units: --1--- Number of bedrooms --Number of baths __ Lot size ------ -------------------- r Water Supply: Public system ❑ Community system ❑ Private e 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: llf 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.), - - __4 Septic nk: Distance from nearest well---4 R r'_Distance from foundation ___.-/_�---r-__.Material----------- ---_-----_-_ _-__-- tr e Iff No. of compartments.--_-___��---______Size- -Liquid --- de th_---.�-�.-.-.- . Ca out /��?' Dispos Field: Distance from nearest well---�9 -----Distance from foundation-----/P Distance to nearest lot line--S...---..._- Number of lines-----------/--------- Length of each line-----/-00----------------Width of trench---{ -.Z__--__-------_------ Type of filter material----__-- ------Depth of filter material_.__/.f-e-._-- Total length----------- --------- Seepage Pit: Distance to nearest well-------_-------------Distance from foundation--------------------Distance to nearest lot line__--------------- JC ❑ Number of pits------ ------------Lining material-----------------------Size: Diameter---------_--_.---.---:Depth-----+,-- --------------------- --_"`_ �' ---- - Cesspool: Distance from nearest well-----------------Distance from foundation------.--------------Lining material ------------_-_.__.----------------. �0 ❑ Size: Diameter------------------------- Depth ------------------------------------k---------------Liquid Capacity---------------------------gals. � Privy: Distance from nearest well.---------------------------------- ------Distance from nearest building____.-----------------------------------._. ❑ Distance to nearest lot line--------- ----------------------------------- --------------------------------- -----•-------------------- -------------------------------- Remodeling and/or repairing (clescribe):-- --------- ------- --- ------- ---------------- -------------••---- --------------------------------- ------------------------------------------------------------ ---------- �X- ` ----------------------------------------------------------------- -------- ---------------------------------------------------------------------------------------------------------- --------------- ----------------- ------------------------------------------------- -----------------------------------------------------•------------------------------------------------------------------------------------------------------------------ - S I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County S ordinances, State I , and rules and regulations of the San Joaquin Local Health District. (Signed)---- --•-- ---- ---------q�� -------- -- ---------------------------- --------------------------------- ----------{ and/or Contractor) By-------- l._-_: ( )------�----- --------------- Title:_-----=----= ----=`--"--'----_- - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- = -- --------------------------------------------- DATE---- j G---------------------- REVIEWEDBY----- --------------------------------------- --------------------------------- ------- ------------------------------------_ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------- DATE------------------------------- -- ------------------------- Alterationsand/or recommendations:---------------------------------------------------•--•------------------------------------------------------•--•-------------•------------------------------- --------- - ------------------------------------------ -- -------- ------ ------------------------------------------•---- --------------------------- ------------------------------------------------------------------ -------------------------------- ........ ----- ------------------------------------------ ---------------------------------------------------- ------------------------------------- ----- -------------------- FINAL INSPECTION BY, .- •� Date------�- -/ -- 41 ------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E,Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CO.