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FOR OFFICE USE: _____ APPLICATION FOR SANITATION PERMIT Permit No. . �. � ------- -- ------- --------- --------------------------- (Complete in Duplicate) --------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued "_l✓`- �' Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descn ed. This application is made in compliance with County Ordinance No. 549. i JOB ADDRESS AND CATIONh- �' '- -f. --yzix--a:Z `''" _ �1 �.t. `L---------------- Owner's.Name t�e� .1R1 -�ij�+f& J-e ------�------- ----------- ----- ----------------- ---- -- -- Phone------------------------------•---- �i• _______. . _�_ _ ----- Contractor's r Address f._ ! ------------ -- ----------- --------- ---- ' i Contractor's '.Name s.Er.:of1 _ -- ----------------------------------- Phone-------------------------•--------- Installation will serve: 'Residence ❑ Apartment House ❑ ICommercial [Trailer Court ❑ Motel ❑ Other [:1 Number of living units:- `__`_-Number ofb�edrdoms`-`_1- Number of baths -------- Lot size ____________________________________________________________ k q as Water Supply: Public system E] Community system ❑w Private ff 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,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 Dispos Field: Distance from nearest well__- Q-_..._Distance from found ation__ZIP__.-.___.Distance to nearest lot line_________________ _ Number of lines-_'_____/----------------_------Length of each line-------7C1.-__------------Width of trench------ -,_____-___________.. ) Type of filter material_________;5--,-)? of filter material------- length___-___7_a �____________________ a � � I ! Seeps Pit: Distance to nearest well__._Ca�.�__._Distance from foundation______/_0-_-"_.Distance to nearest lot line F Number of pits----------l---------Lining material-------- -41_1__-Size: Diameter------V--- r.--___Depth_..__p�4?______._________; i Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- ❑ Size: Diameter----- - ------------------------------Depth-----------------------------------------------------Liquid Capacity---------------------------gals, Priv Distance from nearest well-------------------------------------------------Distance from nearest buildin { ❑ Distance to nearest lot line---------------------------------------------- ------------------------------- ------•- --------------1------------------------------------ I r Remodeling and/or repairing {describe:. . Ce ...�. -�-�=--- -- -- .- ---------------------------------------------------------------------- =� = --------------------------------------------- ------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State ws, and rules an ,t ulations of the San Joaquin Local Health District. a (Signed)---------- ----- ------- ----- ----- - ----=---------------------------------------------------------------------------------------- and/or Contractor) By:. -- r--------- --- -----�-`�-J"�-----------------------------------------------------(Title)--------------- --- -------- -------------- ------------------- (Plot plan, showing size of lot, location of ystem invrelation 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----------------------- -------------------------------•---------------•----------•------------•----------------•---•--- -------------------------------------- 1 -------•---------------------------- --- ------- - ---------- -----------------------------------------------------•--•------ - -------------------- --------------------------------------------- -- -------------- - ------------—... --------------------------------------------------•----------- ---------------------------•------------------------------------------------- --------------------- - ---------------------------- FINAL INSPECTION BY:.... ..s_ _-- _-- ..................r-.�--------- --- YJ �+1Uif Date - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Harellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th street Stockton,California Lodi,California Manteca,California Tracy,California F.R.0 O.