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r FOR OFFICE USE: ------------- --------- ---------------- --------- APPLICATION -FOR -SANITATION PERMIT Permit No. _. .�P.. ----- -------------- -------------- - - --------------- (Complete in Duplicate) .--____._-.-.. This Permit Expires 1 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 thew rk here de ibed. T is application is made in com fiance with County Ordinance No. 549, JOB ADDRESS AND LOCATION--------------------------------------------- ------------------------------- '!'1 Phone ------------------------------- Address.-----------•- --f :.. 1 �-• •----•-------------------•--------------••-•------ ------------------------------------------- Contractor's Name---------17 tr ? -------•-•------••---------------------------------------------- ------ -------------------•---------- ------ Phone--------------------_------------ Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑� W/ Number of living units: -------- Number of bedrooms .------- Number of baths -------- Lot size _- --- ----------------------------------- Water Supply: Public system ❑ 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 ❑ Y Previous Application Made: (if 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.) Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material .-..-.-----....___-_ [] No. of compartments----------------- --- ----Size----------------------------_--•Liquid depth----------- --------Capacity----------------------- Disposal Field: Distance from nearest well------------- Distance from foundation.-------------------Distance to nearest lot line--___---.-----1 ❑ Number of lines---------- -------Length of each line------------------------------Width of trench.-------------.-------------------4 Type of filter material-------------------------Depth of filter material....-----_-----------.Total length-------------._.--------_---------------.i . Seepage Pit: Distance to nearest well----------------------Distance from foundation------------........Distance to nearest lot line--------__.------i _p ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------._-_----.--------; Cesspool: Distance from nearest well-----------------Distance from foundation-_----------------..Lining material--------- -------------- -------------- Size: ------Size: Diameter. -------------------------Depth ------- ---- - lapacity_------- ----------------gals.; Privy: Distance From nearest well-----�---------------------------- _._Distance from nearest building. � �-- _ �-------------- --- - - � } Distance to nearest lot line---- f' ' --------------------------- ----------------------- ------------------------------------------------ ----------------- -� Remodeling and/or repairing (describe):—"" tl -- ,=-"-I--------------------;------i+ -------- ``= = �"` F_'` -•. -x� ,� ---, r --------------------------------------- ------------------------------------------------------------------•------------------------------------------------------------------------------------------------- -------- ---------------------------------------------------------------------------------------------------- ------------ - 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 laws, and rules and regulations of the San Joaquin Local Health District. -4- (Signed)---- `{ "_ 1 -- ----------------------------------------------------- --------(Owner and/or Contractor), B -------- -(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 ACC EPTEb BY ----- --------------------- DATE-- h --------------- - REVIEWEDBY---- ----------------------- ------ --- ----- ------ - ------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED----------------------------------- ------------------------------------------------------------------ DATE----------- ------------------ ------------------------------ Alterations and/or recommendations:------------------------------ ---------------------------- -----------------------•-••---------------------- -----•------------------------- ----------I------------------------- -------------------------------------------------------- ------------------•---------------------- ------------------------------------------------------------------------------------- 1 ----------------------------------------------------- -------- - - -------------------- --------- ---------------------- --------•-- ---•----------------------- -------------- ------- ------------------------- I --------------------- --- -------- ----------------------------------------------- - ------------------------ -•------------- ------------------------------- -- ------ ------------------------ ------------------- ' FINAL INSPECTION BY: - ' - --------- --------------- Date--- ��' - ------- - ---------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hacefton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.RC O.