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FOR OFFICE USE: --------------------------------------------------------- Z k 60, _ v�s-e-�- Ll Z (o _____________________________________________________- APPLICATION FOR SANITATION PERMIT Permit No. .� ... - --------------------------- --- (Complete in Duplicate) Date Issued 0_7:_/ 7 � --------------------------------------------------------- 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 County Ordinance No. 549. JOB ADDRESS AND LOCATION. ------- ---- --------- ----- --------------------------- Owner's Name--- ---— --- ------------------------------------ ------------------------------------------ Phone------------------------------------ Address ----------•--- ------- - - ----+-- -------- --------------•------------------------------- ---- ------------------------------------- Contractor's Name-------------------------------- - - -....------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence e--A--partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms __lumber of baths J___ Lot size ____---________----____________________--_---.-___---____ Water Supply: Public system ❑ Community system 13--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: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tan /1 0' Distance from nearest well-----------------Distance from foundation__--___--__--__--.Material----__--______-_____-_______-.--_-______- \ Elv �, No. of compartments-------------------------Size-------------------------------Liquid depth-------------- ----------Capacity---------------------- Iw Disposal Distance from nearest,v�,ell-_ _&X Distance from foundation_4er------------Distance to nearest lot line«______________ "( Number of lines_________ _______ _ __L n th of each line_____.7&4__---_-- ----.Width of trench__-_�_�______-_.-____.__ Type of filter material-_ .-A---- -� pth of filter material_.__-/�--_------Total length---------�--------------------------- 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. W Privy: Distance from nearest well_-----------------------------------------------Distance from nearest building------------------------------------------.. q ❑ Distance to nearest lot line'- -�--©--D---------------------------------------------------•-•-------------------------------------------------------------------------- Remodeling and/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 rules and reg ations of the San Joaquin Local Health District. (Signed) �11 ----------------------------------------------------- ---(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--- -- --- -- - - ------ - / -G-------- ------------- -- REVIEWED BY---- -- -- - - - - -- -- - BUILDING - BUILDING PERMIT ISSUED---------------------------------------------------------------------------- -------- --------- ------------- Alterations ____:-Alterations and/or recommendations:-------------_---_ ____.____. ____-.-_-__. \__----- --------------- --- - �Q f ___...____-_ __----- .-_-__-...___- _ -.__.__..------------------ -_-_-..------_------_--__-__-_-_.-_----__---_-___-___--_____---_-___-___ __-__.-__- - ------_- -_--- FINAL INSPECTION BY: - - - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haielton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CC.