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FOR OFFICE USE: ------------------------------------- -------------- Permit No. APPLICATION FOR SANITATION PER ----- ------ ----------------- ------------------------ � - --------------------- ---------- --- (Comprete_to Duplicate) Date Issued . ------ -�'�� --------------------------------------------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Locale Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. ?e7 Wj JOBADDRESS AND LOCATION-----:"--''-~----------------------------------------------------------- ------?-------------------------- -------------------------------- Phone--------- -------------------------- Owner's -- ---------•---- Owner's Name----'� '_..................` ' -= r ------------------------------------------------- ----------- --------- Phone--------- -------------------------- �- --- ------- Address-_---------�� ------� '�----- :L_4--4----------------------------------------•---------------- -----•------•-- --------------------- Contractor's --,-----•----------------•-------•---------------•--------- ------ ------------------------------------------------------- Phone----------------------------------- Installation ------•-------- -•Installation will serve: Residence[] Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .._1--- Number of bedrooms __ .- Number of baths[�J<f Lot size .- '-- --•------- Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table 1_�?_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam I] Clay ❑ Adobe [2 Hardpan Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION_AND..SPECIFICATIONS:. _L . - - - -- - - - (No septic tank or cesspool permitted if public sewer is available within 200 f4t.) Septic Tank: Distance from nearest well--1-s b?__.- Distance from foundation___ n--------!Material--..�------_�`------------------- No. of compartments-------------- Size �-_ _ Liquid depth') ------- ---------Capacity-- �.7_R- Disposal Field: Distance from nearest well.. ��---'-Distance from foundation.-ii t'.-- ----Dist{a'nnce to nearest lot line--r.._....... r� Number of lines------- '---------------------=Length of each line..---- - -- ---------Width,of trench---"---------------------------- ` O b Type of filter materiai__A,'�_=---------r.Depth of filter mater3aLI-------.-___..Total length---..._____---------------_--------..- i Seepage Pit: Distance to nearest well._1._`,..C_-....---:Distance from {"dirtion__.. "'t`... ,._.Distence to nearest lot line•{._......---- ❑ Lining material-- - -t ---------Size: Diameter. --7....._.-----Depth--�-5---------------------- �. Number of pits-___'�.---..._._ Cesspool: Distance from nearest well...............'_Distance from foundation-....... ----------.Lining material-----__-------------.-------_----- ❑ Size: Dlameter-------------------------------------Depth_.---•--�-------------------------- -------------Liquid Capacity---------------------------gals. Privy: Distance from nearest wellti � ------------------------------ -Distance from nearest building--------------------------------------- ❑ Distance to nearest lot line--------------------- Remodeling and/or repairing (describe):-------------- ----------------------------•-•------------------------------- ------------------------------------------------------ -------------------------------------------------------- -----------------------------------------------------•--------------------------------- ------------------------------------------------- -------------------------- ----------- I ------------------------------------------------------- --------------------------------- --------------------------------------------------------------------------------------------------------------- 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. �t 7 _� + ------------- --- -------Owner and/or Contractor( (Signed]. _-------------------- - - ----------- ---- --------- -- ----- - ----- Tale - - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY . . .. .r a_� - ----------- ----------------- APPLICATION ACCEPTED BY.. ---------------------------------------- REVIEWEDBY------------------------------------- ---------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------- ---------------------------------------------------------- DATE---------------------------------- ----- -------------------- a Alterations and/or recommendations:-------------- ---------------- - -------------------------------------- ------------------ -------------------------------------- --------•------------- ,2- -ads G 7 FINALINSPECTION BY- --- - - - ----- ------------- Date------- -------------- --------•------- ------------------ ------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9Th Street Stockton,California Lodi,California ym Manteca,California Tracy,California F.P.E O.