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FOR OFFICE USE: % --------------------------------------------------------- -__----------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ..{�.�. . -------------------------------- ---- --- --- ---------- (Complefe 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 work herein des d This a plication is made in compliance with County Ordinance No. 549. OoS- l ev-(0 y JOB ADDRESS AND LOC ON_�_�_._ ,�,.t _:_ ��f vn-_. __._ __ "--'e - --•--- - -•------------------' R Owner's Name---Ff-F�-•�•--• --- ---- Phone ----- ------------- r Address.---- ---•- - -- -------- ---- . •-- ------------------- Contractor's Name---------- - ------,•----- Phone------------------------ Installation will serve: Residence Apartment ouse ❑ Commercial ❑ TrailerCourtCourt ❑ Motel ❑ Other ❑ Number of living units: ___ Number of bedrooms ,F Number baths _,If!_ Lot size ----- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table ___.____ 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 11] New Construction: Yes E]E] FHA/VA: Yes E] No ❑ -` TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permiffed if public ewer is available within 200 feet.) f _ Septic n : Distance from nearest well ®___.Distance from founda 'on____I_e_____.__.M, --------------aIterial__ �gr___-_____. No. of compartments______ iquwd depth--- � LCapacity .d Dispos Field: „Distance-from-nearest' -ell_..._�`_'d------Distance from foundation----/,0_�.......Distance to nearest lot lifne__�p___-__. Number of lines__________._ Length of each line_______-1Q(�____-____.Width of trench.___`..____ f. 7------------------ Type of filter material'" _._.____ .___`_Depth of filter material__-- - _--____`__Total length-----�{�1�__________________________ f E Seep, a Pit: Distance to nearest well___.__f-©G__-__Distance fro four dation_____ ------Distance to nearest lot line_� � __ ____ Number of pits---------/.___.__Lining material__ ____ Size: Diameter-____ _ _ iP Cesspool: Distance from nearest well----------------- from foundation-----_------------_Lining material---------------------------------- El Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------._.________-____ ❑ Distance fo nearest lot line------------------------------------------------------------------------------------------------------------------------- ------- ` Remodeling and/or repairing (describe):-------------------------------- ------------------------------------------------------------------------------•------•-----------...---•--------•- `� -----------------------•-------•-------•------------------------------•----•--------------------------------------------------------------------------------------------------------•---------------------------- - ------ ------------------------------------------ ----------------- ----------------- ------------ -------------------------------------- --- --- ------------------------------ I hereby cerfi that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sf I s, and rules an gulations oft an Joaquin Local ealth District. v . OF C, (Signed)------ --- -- ------ ----------- - ---- --- ------ ----------- -- ------------------------------- . --- ner a d/or Contracto By:--------- - --------------- -- ------ ---------- --------- --- ----------------------------(Title}---------------------- --------------------------------- (Plot ---------------- ----- -- (Plot plan, showing size of lot, location of syste in relation a wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE.. �.-...' ---------- REVIEWED BY--------------------------------------------- -------------------- ----------------------------------------------------------- DATE--------- ---- ------------------------------- BUILDING PERMIT ISSUED---------------------------------------------------------------------------------------------------._ DATE---------------------------- --- ------------------------- Alterations and/or recommendations-------------------- ---------------------------------------•----------•--------•------------------------------•----------------•------------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------•---------- ---•-------•------•-----------------------------------•-•------ ------------------•---- ----------------------------------------------- - -----------•----------•--------------------------------------•-------------.---------------------------------------------------------- --•------ ---•-•-------------------------------------------------•--------------------- ------------------------------------------------------------------- -------••----------------------------------- ------------------------------ ----------------------------- -------- -------- ------------------------------------------------------------------------------------------------ -------- ------------- ------------------- -------------------------------- FINAL .INSPECTION BY:...4yt ------------------------- Date__-/�'�.`3--"`3 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 Fs 9 REVISED 0-59 3M 3-163 F.P.CD.