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FOROFFICE 115E: ----------------------------------------------------- -- APPLICATION FOR SANITATION PERMIT Permit No, .-,-2 ----------------- --------------------------------------- 1 . (Complete in Duplicate) Date Issued ____ .- � ---- ---------- ----- This Year From Date Issued 02- Application is hereby made to the San Joaquin Local Health District for a permit to-cpnstr��uc a d install the work herein described. This application is made in compliance with County Ordinance No. 549. �. �� �1�M,5- w- -U-A. j5-ve- ' JOB ADDRESS D LOCATION• �?_�------ ------- -t x `�._._� �4-Cr- :------------------------------------------------------------ + f /� Owner's Name------�-�sl-------------fll�-f�6-d 5�Q1�-------------------------------- ------------- ------------------------------------- Address......... ------------------ -----Address----..... ...... - ® -------��`�r -Z-------------------------------------- �� -•- Contractor's Name- -Nr �] e--------------------------- Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --/--- Number of bedrooms -/--- Number of baths --/---- Lot size _______ ______ ________ _----_____--_ Water Supply: Public system ❑ Community system ❑ Private [ Depth to Water Table -Y-b ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam XI Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan [ �' Previous Application Made: (If yes,date--------- -- ---- No R New Construction: Yes Er"'N'o ❑ FHA/VA: Yes ❑ No E 0J 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-----------------Distance from foundation--------------------Material..-.----.-_---..---_------------__-_...____-___. ❑ No. of compartments-------------- -----------Size---------------------------- ---Liquid depth----------------- --------Capacity------ ---------------- Disposal ------------ -- A Disposal Field: Distance from nearest well-1 ..._Distance from foundation-_-y0__-----_-.Distance to nearest lot li ,�7 Number of lines-------•-- ---------------------Length of each line----_--_-1s0- -__-_--.Width of trench.---�_Y_��------------_--_-- Type of filter materiai--- ff.�rS-------Depth of filter material______� __`_�_.__._Total length--------�_Q© ��-----._ 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__.___-----_._----.._------.-------_ ❑ Size: Diameter- --- - --------- -- ----- ----- ----Depth--------------- -----------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well__________________________________________ __7 _.Distance from nearest building----- .-___----._.__--._-----.._-..-__---- ❑ Distance to nearest lot line------------------------- ------------f----------------------------------------------------------------------------------------------- i Remodeling and/or repairing {describe):--------------------- -------------------------------------------------------------------------------------•-------••---------- -----------•-----------•••----------------------------------------------------------------------------------------I--------------------------------------------------------------------------------- - ------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ...... I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)----- ---- - ----- ------- -- -- -- ��-�-___ ___ ___ ._ _ _ ractor )wneranor Cont - ----- ---- -- -------------- ____ __ _____ , (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--13-- T--=G- ------------------------------ - REVIEWEDBY--------------------------------------------- -------------------------------------------------------------------------------- DATE------------------------ -------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------•---------------------------------------- DATE--------- ------------------------------------------------ Alterations and/or recommendations--------------------------------------------------------------------------------------------------------------------------------•------------------------------- ---------------------------- ---------- - -------------------------------------------------------•-----------•----------------------------------------------------------- -----------------------------------•- -----------------•----------------- --------------------------------•--i---------------------------------------------------------------------------•------------------------------- FINAL INSPECTION BY:- - ----------------------------- Date- - �----------------------------- ------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxellon Avo, 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California r.a.c o.