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FOR OFFICE USE- t-k Qb F � Syo yV)nw�_ 1 Z k } _-----_---------- -_-------________________---- APPLICATION FOR SANITATION PERMIT Permit No. .�,:L ---------- ------------------------------------------ (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 County Ordinance No. 549. r% JOB ADDRESS AN _LATION- -------------------------------------------- ` " -r�:--�' Owner's Name__ L_t_-- '------------------------ ` - �-- Phone---------------------- ------- A Address r ==-------•--------- - ------------------------------------------------------------------------------------- -------------------- - Contractor's Name------------ --------------- =------ -- --•--------------------------------- Phone................................... Installation will serve: Residence �x Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .____ Number of bedrooms ____1-_ Number of baths ____ _ Lot size _______ ___. C___jU ____..__..__.______ 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: �J (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ` C?Y�t� 1' r� _Mate �� V Se tic Tank: Distance from nearest well_) __-___-.__Dista fro �ounda�ti /// __________. No. of compartments_ Size.. _' Liquid depth ----- __Capacity _ _(_�__..__. - - �C -------- Disposal Field: Distance from nearest well _)b._'-._--- istance from foundation._-: ' .......Distance to nearest lot li e__ ..____. Number of lines____/-_.---_...-_ Length of each line_____``. _C)_______ ________Width of trench.__-. .� _ i? 'I ��-- . Type of filter mate ria l"?__I-��-:e Y _:Depth 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. Privy: Distance from nearest well------- - -------- -__-__ .._--_._-.Distance from nearest building------------------------------------------ n __-_ _______ ____________.__ -._.❑ Distance to nearest lot line--------------------- -------------------------•- --------------------------------------------•--------------------------------------- ` Q 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, ate laws, and rules cAd regulations o., he Sa Joaquin Local Health District. (Signed-------------------------��-------------------------------- -- ------------------------------------------------------------------------------------------(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 - - ------- ----------------- --------------- -- --- DATE - REVIEWED BY - DATE- -,. � --- BUILDING PERMIT ISSUED........._______________________________._ ------------------------------- ---------=_=----= ---- DATE----------------- :�a-------------------------- Alterations and/or recommendations------------------------------------------------------ --------------------------------------------------------------------------------------------------- ----------------------------------------- ------------------------------ ---------------------- ------------------•----------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------ ------------------- -------------- ------ --------------------------- ----------..------ --------- ---------- ------------------------------------------------ -----4. ---------------------------------------------------------------4-. -.. ------ -------------------'--------- r FINAL INSPECTION BY:---------- --- - ------` ------ Date-.------ - . ---- U 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.CO.