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OFFICE USE: - =1 ----------------------------�1 ------ --- ------- ---------------------------- APPLICATION FOR SANITATION PERMIT Permit No. in Duplicate) - ---------- ---- -----------=---- ---------.- This Permit Expires 1 Year From Date Issued 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 Count Ordinance o. 549. f JOB ADDRESS AND OCATIO ___. __f1 - Owner'sName. ----- Phone-------------- ---- ------------------------------ --------- ----- ------------------------------- - Address___ Contractor's Name--- T - Phone r Installation will serve: Residence 'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___7_ Number of bedrooms -_L,_ Number of baths _1___ Lot size -----44?_k11. 2--------------------------- - - Water Supply: Public system Community system ❑ private [] Depth to Water Table fa-.A ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [jHardpan ❑ Previous Application Made: (If yes,date___----__-------__---) No New Construction: Yes ❑ No t— FHA/VA: Yes ❑ No ®� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sepjrc lank.' Distance from nearest well-----------------Distance from foundation------------------- Ma#erial___-._____________._____-._____.____.._._____.__. f No. of compartments---------- ---------------Size-------------------------------Liquid depth-------------------- ----Capacity----------------------- Disposal Field: Distance from nearest well_----—___-__Distance from foundation__j�g_.._____---Distance to nearest lot line----U` J__ 8 Number of lines---Z-----------------------------Length of each line------3,-_`---_--------.Width of trench._-2-jK--"----------_--------- Type of filter material _-7./f_.......Depth of filter material___1_e_r_'-___.__._Total length-----------'74--`____________________ Seepage Pit: Distance to nearest well__ _________Distance from fondation----- d_�___.Distance to nearest lot line_._- -• J Number of pits_-___f------ --------Lining material--- <-,-�---Size: Diameter-----�-�3-- -.--. Depth_...__�'�-------------- Cesspool: Distance from nearest well----------_------Distance from foundation___.._----------_Lining material_...____._._____----__..______---____. N ❑ Size: Diameter------ --------------- ----------------Depth---------------------------- Liquid Capacity gals, Privy: Distance from nearest we]________________...____________.__-_-_.____.____Distance from nearest building____-____..___-_-.__________.._.__.__-_. ' tea: ❑ 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, jA rules and regulations of the San Joaquin Local Health District. (Signed) C ' � i ------------------------------------------ and/or Contractor) By: ---------•---------------------- ----------------------------------------------------------------- ----------(Title)------------------- -- -----=--- -- - - --- -- --------- .. (Plot plan, showing size of lot, IoCation of system in relation to wells, buildings, etc., can be placed on reverse side). t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- ------- - ' REVIEWED BYDATE_. '" ------------------------------ --------------------------- -------------------------------------------------------------------- DATE------------------- --------------------------------- BUILDING PERMIT ISSUED------------------------------------------------ ----------•--------------------------------------. DATE.---- Alterations and/or recommendations:-----_.._..---- --- ----------------______- - ......:;T ----------------- ---------------------------------------------------------------------------------------------------------------------------------------------- -------- ---------------------------------------------------------- ----- - ----------------------------------------------------- -- ----------------------- ------------------------- ---------------------------- ---- .. . F1NAL INSPECTION BY:-'---J--------�J-------------------- - � - -------- -� �_ Date...... �..-��..- ------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi, California Manteca,California Tracy,California F.P.CQ.