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FOR OFFICE USE: --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ., / .� -------------------------------------------------------- orl, (Complete in Duplicate) ____________________.___ 1 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 No. 5 , JOB ADDRESS AND OCATIO -----------_ Owner's Names.,4 ----- --- - _ -- Phone -----------:------ ----- M------- Add — -------- ---------- ---------------------------------------------- . a .',-- Contractor's Name ?- c-':.�rl -` --------- =---------------------------------------- _- Phone................................... Installation will serve: Residence partment House ❑ Commercial Trailer Court ❑ Motel F1 Other ❑ Number of living units: __- ___ Number of bedroo s Number of baths ------- 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 New Construction Yes ] No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: p ( septic p p p is available within 200 feet.) No se tic tan or cesspool permitted if /�/��s�er a e fro ound tion__.f�'�_.______.Materi I :____,: ..��_f=•_G_S�_-�--��._... Se Tank: Distance from nearest well__L -__.____ _Dist 4 _____ 1 �> ] No. of compartments_____,___--_ -Siz ( .-X-__Liquid depth_.-_-_._._---__._Capacity.f__'4__._` _ Dis al Field: Distance from neatest well_/t�1 �+Distance from foundation.. Distance to nearest lot li e� f�°�r� ® Number of lines_________,._. Length of each line_ ___�_ ��idth of trench '/ __-____-__ Type of filter me ----- Depth of filter material__,�.��---- ------Total length--------I& _______________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line_____.__-_____-__ ❑ Number of pits____________________Lining material-----------.-----------Size: Diameter-----------------------Depth--------------______-_-_.______ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------____ ❑ Size: Diameter-------------------------------------Depth---------------- ---------------- -----------------Liquid Capacity..---------------------....gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building- ------------_------------------___-.._. ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------------------------------------------- - Remodeling and/or repairing (describe):------- --------------------------------------------------------------------------------•---------------•----------------------------------------------- ------------------------------------------------------- ---------------------------------------------------------------------•-------------------- -------------------------------------------------------------------------- ------------------------------•-----------------------------•--------------------•------------------------------------------------------------------------------------------------------------------ ------------- ------------------------------------------•-------------------------------------------------------------------------------------------------------------------------------•--------------------------------------- -- I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County \01 ordinances, St,4te Jaws, and rules and regulations of the San Joaquin Local Health District. (Signed)------/11_1__�____/_/__/_�---.-----------J -='---------`--'---�- -------------------- --------------------------- --------------------------- -------(Owner and/or Contractor) By:-------------------------------------------------------------------------------------------------------•----------------------------(Title)--------------------- ----------------------- -- ------------- (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 APPLICATION ACCEPTED BY--------------------------- -------------- -------------- i -------------- DATE---------------------- j �" REVIEWED BY DATE �. _�_.i ------------------------------------ BUILDING PERMIT ISSUED------------------------------------------------------------------ - ------ DATE-------------------- --------------------------------------- Alterations and/or recommendations--------------------------------------------------------------------------••-----•------•-------•------- •---•--------•----•-------------------------------- ------------------------- ------- --------------------------------------------------------------------- ----------------------------------------------- •----------_.._ ....... ---- --------------------•-- -------------------------------- ------------------------------- ------------------------- --------------------------------------------------------------------- ----------------------------------------------------- ----------------- ----------------------------•------------------------------------------ ---------------------- ---------- ---------------------------------------------------------------------------------•-------------- ------------------------------------------------------------------ --•- --- -- ---- - --- - -------------------- ----------------------------•----- -------------------- --------- ---------- ------------ FINAL INSPECTION BY------------ --- ---- ----------------------------------- ---------- Date----A -------- --------------------------------------------------------- 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