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APPLICATION FOR SANITATION PERMIT Permit No. ------ (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein Ascriked. This applicafion is made in compliance with County rdinance No. 549. H Ali- 1�0 JOB ADDRESS ASD LOCATI N - --- '--•-- - ----- -------- --- --- ------ '14 L Owner's Name- ----------- - -- - - --------- ----- Address ------------- ----- ---- ------ --- ---- ----------------- ---------- Contractor's Name--- -- ---------------------------------------- ------------------------------------------------------------------------- Phone-- Installation will serve: Residence Apartment House 0 1 Commercial F1 Trailer Court 0 Motel 0 Other 0 Number of living units: Number of bedrooms 4-- Nu;Aher of baths Lot size --------------------- Water Supply: Public system ❑ Community system F1 PrivateXrDepfh to Water Tabl,,Zl--- ft, Character of soil to depth of 3 feet: Sand GraveIE] Sandy Loam r] Clay Loam Clayo Adobe [_-] Hardpan El Previous Application Made: YesE] N OX New Construction: YesA NoEl FHA/VA: Yes El I NcjT- 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------------------------------------------------ U No. of compartments--------------------- ----Size--------------------------------Liquid depth---------------- --- Capacity----------------------- Dispo I Id: Distance from nearest well_________________Distance from foundation--------------------Distance to, nearest lot line___-____--___-_-- 17,field: Number of lines-----------------------------------Length of each line-----------------------------.Width of trench------------_- ------ -- Type rench-------------------------------- Type of filter material--------------------------Depth e of filter material--__--_______--___ --Total length-_______________-_-___________________ fflnda Pisf, Seepage Pit: Distance to nearest --------Distance from f fin e nce to nearest lot line Ile 01 dumber of pits-----/-------------L�' Numb iing lmaferiaL-1-1-�o--- - -----Si Di te, ------- - ---.Depth---r 0 ----- X P 110'. t* Cesspool: :-.Distance from nearest weJI-----------------Distance from founclafion -------------------Lining material----_---------------____-_------_-___. �� ❑ aterial------------------------------------- D Size: Diameter------- ----------- -------- ----- ----Depth------ ---------------------------------------------Liquid Capacity----------------------------gals. .'rivy: Distance from nearest well-----------------------------------------------.-Distance from nearest building____-_________________________________--_. ❑ uilding-------------------------------------------- F1 Distance to nearest lot line------------------------------------------------------------------------------------------ ------- ------------------------------------- P-e -jng and/or re a- i`ng (describe 00, - - --------- ------------------------------------------------------------------------ --------------------------------- -------- ---- ---------- ------- --------- ---- ------- --------- --- - ------ -- -- ----- ------ --- I---_-k_A7?------------------- --------- -::::-:�7 I --------- ----------------�1---------- ------ ---------- -- - -------- -----------------0---- --- ----------- P e in accordance wit n Joaquin County I hereby certify that I have pre ared this ap I" 'on and that the work ill 6 on quin of e Sa oaqu, 'Nis+r ordinances, State Imsend rules regulafl ns in Local Health icf. (Signed)- IF, I {Own nd/or Contractor) --- --------- ---- ----------------------------------------- ------------- ,- B ------- ------(Tif I -- ----------------- ati 0 ; -j. (Plot plan, sho lot, loc s st e a ion wells, buildings, etc., can be placed on rev�, e�eiie I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------- -- ------ ---------- ----------------------------------------------- DATE------ REVIEWED BY----------------------------------------------------�--- -- -----------------40------------------------------- ---------------. DATE------- -<....... ----- ------------ BUILDINGPERMIT ISSUED---------------------------- --------------------------------------- --------------------- DATE---------------------------- -------------------------------- Alterations and/or recommendations:-------- --------------------------------------------------------------------------------- ------------------ ----------------------------------( ---- ------------------------------------------------------------t---------•-.---------------- -------------------------------- ------------------ -------•-- - -------------------------- ------------------------ -------------------------------------------- ------------ -------------------------- -- ------- -------------------------------------------------------------------------------------- ----------------------------------------- -- -- ------------------ - ---- - - ------------------------------------------------ ----------------------------- �-FINAL INSPECTION BY:.!,- - -------------- ---- -------------------- Date-------------------------------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wesf.,.Oak'Streef 132 Sycamore Street 814 North "C" Street W Sfock+on, California Lodi, California Manteca, California Tracy, California ES-1-2m Revises )-57 FY.00-