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FOR OFFICE USE: ro a j Ik�y - -Dy1 Z Ic APPL CATION FOR SANITATION PERMIT Permit No. 55�Q10_.32 ------------------------------- (Complete in Duplicate) Date Issued ____________-----------------------------------.---- I 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 described. This application is made in compliance with CourIfy Ordinpcj No. 519. JOB ADDRESS AND LOCATION------------ / M -! Owner's Name------------- -•--- ---(r---------- - - • --------- -------------------------------------------- Phone------------------------------------ Address ---------•------••--•--- _ Address----------------��--��---�-7---------- --------- ----------- - - ---------------------------•--------------------------------- Contractor's Name------------------ �--J -------------------------------------------•--•-------------------•------•--•--- Phone..4 .�-'1..71__... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ________ Number of bedrooms _/____ Number of baths ________ Lot size ________________________________ Water Supply: Public system ❑ Community system ET""Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 2' Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No New Construction: Yes ❑ No FHA/VA: Yes ❑ No 9 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspbbi permitted if public sewer is available within 200 feet.) rSeptic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material ________._--__.____._________-_.___--_____. �v No. of compartments--------------------------Size-----•---------•-------------Liquid depth------- -----------------------------Capacit6- Disposal Field: Distance from nearest well._.�_� TDistance from foundation---�.o?-__.___.Distance to nearest Iot)ine.-S..__..... Number of lines----------- Length of each line------- of trench____________ s. g ./ y ------------ Type of filter mate ria l__f_ __l� c< .Depth of filter materiaL,f�____-________Total length------------Z____-__-__f.___-_______ l 0 See pag it: Distance to nearest well_____/4 __ _Distance f�m dation -__..._.__..Distance to nearest l``o�tt lin __ -________- V� Number of pits-------/----------Lining material__`�Z_ C-- Size: DiameterlQJX_/;=-----Depth_.--_T-- -------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material----------.___.____________________. ❑ Size: Diameter----- --------------- --------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest weft------- ------------------------- Distance from nearest building------------------------------------------- Distance _____ ____________._ .-___._.Distance to nearest lot line.-------------------------------------- -------------------------------------------------------------•-------------------- ------------- �sls; Remodelingand/or repairing (describe):-----------------------------------------------------------------------------------------------------------------------------------...................... •----------------------------------- ---------------------------- ------------•------------------------------------------•------------------------------------------------- --------------------------------- ----------------->------ -------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------- 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 rulef and regulations oft an Joaquin Local Health District. (Signed)-------------------------------- ----------------(Owner and/or Contractor) 1 g (Title)_ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 1 FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY---------------------------- ----------------------------------------------------------------- DATE------------------------- --------------------------------- REVIEWEDBY--------------------------------------------- •--------- ------------ ---------------------------- -------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations------------------------------------------------- -------------------------------------------------------------------------------------------------------•----- ------------------- ----------------------------------- ---------------------------------------------------------------- ------------------------------------------------------------------------- ------ ------------------------- -----------------•- -------------------------=----------------------------------------------- --------------------------------------------------------------------------------------- -----•---------------------------------------------- ------------------ ----------------------------------------------------------------------------- --------------------------------------- ---------------------------•- FINAL INSPECTION BY:. - - ------------------------------------------ Date ---------------------------- SAN ------- ------------- 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 F.P.CC.