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FOR OFFICE USE: -------------------- ---------- GG' --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ...�/.1. �. --------------------------------------------------- -- - (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 w9rk heraip described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCA9N------ --------------------- .........0 Owner's Name------------- - ---•-- ---A-1-11 ------ ---- - ---------- --- ------------------------------- P one _—_-= ...,-------------------- AddressC• ..... -- --�----- - ------ ---------------------------------------------------------------------•--------------------------------- Contractor's Name-------------------- 1..� Phone---------.........= Installation will serve: Residence1Q/Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __.----- Number of bedrooms ---)i--- Number of baths -------- Lot size ---------------'�I_. .X -e-C--___--_-__-_-_-__ Water Supply: Public system ❑ Community system Private ❑ Depth to Water Table 1_yft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam R/Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) SepticTank: Distance from nearest well_/fG------Distance�jom fo�datio Material_ 19/ No. of compartments_.__ ___.__._.___Size_9_ __.,cr ,�. squid depth_--- - �_______--_Capacity...1 �...... Disposal Field: Distance from nearest well_l ._Distance from foundation;_.��.______�__.Distance to nearest tot line_47._..._.. Number of lines----------- _Length of each line.�5_'-2a'_1-•"__-lidth of trench_____02--------_.._____-__-_--_ -i Type of filter material-/-"T__� _ _ epth of filter matenal____)_o0___�___Total length______-___ J ____.__.__________ 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-------------------- --------------------------------------------------------------•----------------•---------------------------------------- Remodelingand/or repairing (describe :---- -------------- -------------------------------------------------------------------------------------------------------------------------------- ------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------•--------------------------------------------------------------------------------------------------------- "V -------------------------------------------------- ----------------------------------------------------------------------------------------------- -------------------------------------------------------------------------- . 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 rul s and regulations of the San Joa uin Local Health District. p � � (Signed) - x�r�l t' ---------------------------------------- -----------(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 APPLICATIONACCEPTED BY--_--------------------------------------------------------------------------------------------- DATE---------------------------------------------------------- REVIEWEDBY-------------------------------------------- ------------------------------------------------------------------------------- DATE--------------- ------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------•--------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations----------- -------------- ---------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------- -------------------------- -------------------------- ----------------------------------------------------------------------------------------------------------- ----------- -------------------------------------- -------------------------------------------------- ---------------------------------- -----------------------------------------•----•---•------ ----------..----- ----------- --------------- ---------------------------------------------------------------------------- ------------------------------ - - - ------ -------------------------------------------------------------------------- ------ ------------------------ ---------------------- -------------------------- ------ ------ FINAL INSPECTION BY:.. - ------------ Date---------- -------- ----------------------------------------------------- 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 P.P.CC.