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NJK Vi-I-K-L USt: ------- -------------------------------- --_---------------------_____-------------_------.-------- APPLICATION FOR SANITATION PERMIT Permit No. ---------------------- --------------------- ---------- {Complete in Duplicate} - - ------------- -- -.--- This PermiDate Issued 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. 549. JOB ADDRESS AND LOC ON j� �1-- -ic�i�.e� _ !jy ,�.P��,��r-� ,. d�PC-------------------- Owner's _- _O`f0_---D2— /�77 Owner's Name-----kr------ ,=o"! 4•------------------•--- --- ------------------------------ Phone-_------- ---•--------------- Address---------- -- W--------------- x t Contractors Name----------- ---- ---------___-• -------_----- Installation will serve: Residence ❑�. Apartment House ❑+ Commercial [Trailer Court 0 Motel ❑ Other E] Number of living units:"'__ Number of bedrooms S` _ Number -baths ____�__ Lot size _:________________________.____-___- ------- Water Supply: Public system El Community system ❑` Private Depth t ater Table _:_____ ft. Character of soil to a depth of 3 feet: Sand [-] Gravel E] Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ jR Previous Application Made: (If yes,date............._.__-.) No [] New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ O TYPE OF INSTALLATION AND SPECIFICATIONS: Q ' {No septic tank-or_cesspool_permitted_if,public`sewer is available ithin 200 feet.} __ Y Septic Tank: Distance from nearest well----- ----------Distance from fouridation-'__`___ ........Material__ ❑ No. of compartments--- Size--- --------------------------t_Liquid.depth----------------- --------Capacity----------------------- Dispo Field: Distance from nearest well __S ------Distance from foundation___.ld._____--'.pistance to nearest lot ' Number of lines_______-_,�______ Length of each'.line_______�Ct�__-___.__-__Width of trench___`_.______-_ --------------- ---- - fA Type of filter ma�erial-------- ____.__Depth of filter material-----/I_.----------Total length-------c�� ----------------------- Seepage - --------------------- 1 Seepage Pit: Distance to nearesf'well----------------------Distance from-foundation--------------------Distance to nearest lot line-------.-___-____ � ❑ Number of pits---1-------------------Lining material-----------------------Size: Diameter-------------.--- -._.Dept h-----------.------------------ --- o Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------_----------------- ❑ Size: Diameter- A------------------- -----Depth-------- - ---------------------- ----------Liquid Capacity_..-------------------------gals. Privy: Distance from nearest well __________________---------------------------- _Distance from nearest building--------------.____- ❑ Distance to nearest lot line (� ------ --- Remodeling and/or repairing (describe):--------- -------------------- ------------------------------------------------------------ -------------------------- --------------------------------------------------------------• ------------- ------------ =------•-------------------------------------------------- - -------------------------------------------------------------- ---------------------------- --------------------------------•----------------------------------------------•------------------------------------------------------------------------------------------------------------- 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. 1 (Signed) -- --------- ------ - ---------------�----- ----- an r Contract B -� o or _ --------------------------- -------------------------(Title}----------- ------- ------------------- ------- _ "(Plot plan,showing size of lot, 1622-54tori of system'in rela ion to wells,buildings, efc.;c n b-pla ed on reverse-side).- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ _ ----- -----_ DATE__ ---- .z-' REVIEWEDBY-- ----------------------------- --------------------------------- -------------------------- ------------------------------ DATE-•-•------------------- - - --------------------- BUILDING PERMIT ISSUED------ - DATE - - ------------- A terations and/or recommendations----------- -------------- - -------------- ------------------------------------------ --------------------------- ------------------------------------------------------ -------------•------------------------------------ ---------- -------- --------------- - -----_--------------------_______....._________-_-_____..--__-__...._..S__-_._____.-_.________._..__.._-.__.______. _ FINAL INSPECTION BY,,,- ----------- ------ Date.2__ ---------- __�� ---- f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ha=elton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi, California Manteca,California :racy,California r.P.CO.