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FOR OFFII-:E USE.`_ " -------------------------------------------------------- _________________ APPLICATION FOR SANITATION PERMIT Permit No. -.).2:�_ . ------------------------------------------------------ (Complete in Duplicate) ----------------------------------------------------"_ 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 wor herein described. This application is made ,in compliance with County Ordinance No..549. (03- 60 —3 3 JOB ADDRESS AND OCATIONW _ ____ _f1-W_1------ .._. _i� �. -------- ; Owner's Name-------------------• � Phone.. ._--------------------_----- ,Address.-- ------•---------------------------------- -------------------•-------------- ..................... , Contractor's Name------------------------- ` -----------------_______-____.-------------------------------------•-._.......- Phone Installation will serve: Residence' A rtment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ____ Number of bedrooms ---Z-- Number of baths /___ Lot sizo '_____________________ Water Supply: Public system ❑ Community system ❑ Private R, Depth to Water Table W'. ft_ Character of soil to a depth of 3 feet: :Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe;[, ' Hardpan ❑ Previous Application Made: (If yes date_- -------------) No �. New Construction: Yes ® No ElFHA/VA: Yes El No TYPE OF INSTALLATION AND SPECIFICATIONS: _ f (No septic tank or cesspool permitted if public sewer is available within 200 feet.) � Septic Tank: Distance froni nearest well.-.:�T_!_Distance from�f,p undation.____C6_�_ <-.t77!'� ' No. of compartments_._-- �-------.`T Siz� _�`___.1%6 --Liquid depth------ - -----------Capacity__ Disposal Field: Distance from,nearest well._--,1 d_ Distance from foundation..._ istance to nearest lot line---------- Number _______-Number of lines-------------t ------------------- Length of each line------------ __.Width of trench____:_______ Type of filter material--- --- of filter material_______ �� Total length____________________ / _.. Seepage Pit: Distance to nearest Distance m f undation----a�____-_-Distan6- 6-nearest lo t line_ _ Number of pits----------- Lining materia � Diameter____ ____--De th_______ -_ � __ Cesspool: Distance from nearest well________________Distance from foundation.-. material----------------- �} I F-1 Size. Diameter--------------------------------------Depth._.-------------------------------------------------Liquid Capacity-----------------------_--gals,1 Privy: Distance from nearest well--------------------------- ------------------- Distance from nearest building------------------------------------------ Distance ---------- -------------------------...Distance to nearest lot line------------_ --------------------------------- ----------------------- --------------- ---i 4. w _ m Remodelirngfand/or repairing (describe):--- --------- ---------------------------- �.... fTl ------------------- -------------••------- r1 -- ; I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County s ordinances, State laws, and rules and regulations of, the San Joaquin local Health District. , (Signed)---W_X,1_ ------------------------------------------------------------ ---(Owner and/or Contractorl- By:------------------------ -----------------------------------------------------------------------------------------------------•--•-(T'itle)----•--------------------------- ;----- ----- ------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPA T�MENT USE ONLY F APPLICATION ACCEPTED BY----- • = ��'---- ------ --- -- ---- --------------------------------------- DATE �. 1�' . REVIEWEDBY------"---------=------------------ ----- - =--------------------------------------- DATE------------ --------------------------- BUILDING PERMIT ISSUED------------ ---------------------------------------- ---•---•-----•- ......-... DAtE------------------------------------------------------------- Alterationsand/or recommendations:--------------------------------------------- -------------------------------------------------------------........................•--------------------------- ---------------------------------------------------------------------- ---------=-----------------------------------------------------•-------------------------------------------------------------------------•-------------- --- -------------------------- ----------------------------- ------------ ---------------------------------------------------------------------••-----•---•--•------------------------------------ r+ •- ---------------------------- -------- ----- --- "- - ------------- - -------------- --------------------------- •-----------------------•---•-------------- f i FINAL INSPECTION BY: --- --- - ---- ---- ------------- -------------- Date------- /G ----------- I ed ------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California .O ES-4 REvis Eo P-Ss r.PMO.2M 6-60 1f