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FOROFFICE USE: 0. s� Q ----------------------- - - - --•--------- _,-.----�-4 ------------- - APPLICATION FOR SANITATION PERMIT Permit No. .. -• •-.-•-. --_ -- ---- -- ---------------------------- ---------------- - (Complete in Duplicate) p 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 described. ' This application is made in compliance with County Ordinance No. 54 JOB ADDRESS AND'LOCION_ ----- -------- --------------- -- --------- -- I---V-6-1---0-q0---0 Owner's NarPe__ ---r ----y ----- - -- --------------------- - ••---- - -------------- --------- Phone-------------------------------- Address-----•----••----•---- lbt_. -- l - t ------------------- -- -- ------ - Contractor's Name--------- - -_ - - - ----•• --- - -- - -------- ------ -- --- -- ----------- ----- ------------- Phone-------------...-----•-----•------• Installation will serve: Residence [❑ Apartment House ❑ Commercial ❑ Trailer Cour/� Motel [:] Other E]Number of living units: �-- Number of bedrooms%S--- Number baths%Is- Lot size ____-___________-_-________________________________ Water Supply: Public system [-] Community system ElPrivate Depth t ater Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel E] 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 permiffed if public sewer is available within 200 feet.) 1 Septic Tank: Distance from nearest well-----------------Distance from foundation-------------------Material-_.-_-___-_________-_____________--____.____.. , ❑ No. of compartments--------------------------ize--------------------------------Liquid depth--------------------------Capacity--- -------------- 1-11 Dispos field: Distance from nearest ell-.-, __-Distance from foundation ___ __�_-Distance to nearest 1 Number of lines_,_______I_-- ----- _Length of each line______ _____________Width of trench Type of filter material-- �L ' ,-Depth of filter material_.__.{ -_-_____Total length____ _______________________________ 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--------__.------------.------------- , 171 Size: Diameter-------------------+------------------Depth----------------------------------------------------Liquid Capacity-- ------------------------gals. Privy: Distance from nearest well______________________ __ ----------------------Distance from nearest building Distance to nearest lot line----- --- --- --- ❑ ----------------------------••- ---------------------- ------- ---- ---------------•-------------------- � Remodeling and/or repairing fdescribe):-------4 ---dC .--- 7 ...../�--- --- ---------------------------------------------- ---------------•-------------------------------------- -------------------------- I hereby c.ertif that I have prepared this application and that the work will be done in accordance with San Joaquin Count Al. ordinances, Stat s, and P.rules and gulatiblm of San Joaquin Local Health District. (Signed]_ ----- ------ - ------ -�--- - - i 'G.[ J--------------------------------- w + nd/or Contractor) --------- ------------------------------(Title)---------------------------- (Plot plan, showing size of lot, location of system in relatio o wells, buildings, etc., can be placed on reverse side). - -~' t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- - --- - ------------- -- ---------------------------------------- DATE__._ :.z REVIEWEDBY------------------------------------------------------------------ -------------------- ------------------------------------- DATE BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------- --- DATE------------------------------------------------------------ Alterations and/or recommendations:---------------- -----------------------------------------------------------------------------•------------- -------------------------------- -1-------------------------------------------------------------------------- -------------------------------•--------------------------------------------------•-•--------------------- ----------------------•------------------------------------------------------------------------------------------------------------------------- ---------- --•-----•------------------------------------• ------------------------------------------------ ---- ----------------------------------------------•---------------------------------------------------- --------- --------------------- -------------------I------------•-------------------------------------------------------------------------------------------------------------•------------------------------------------------- NAL INSPECTION BY,�- - ---'-- ----- ----------------- Date.-6 ''o�-J SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9Th Street lockton,California Lodi,California Manteca,California Tracy,California mai 9-59 3M 3••63 F.P.120, y